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Women Centred Health Project
Report of the End Evaluation
(1996-2003)
Women Centred Health Project
Public Health Department of Municipal Corporation of
Greater Mumbai
Society for Health Alternatives (SAHAJ)
Royal Tropical Institute (KIT)
.LUU U i
Other Publications.
1.
Gatha Stree Arogyachi’ — a resource book on reproductive health for health
workers (Marathi)
2.
Puja Roy Women Centred Health Project, Prioritising Urban Women’s Health
Issues in a Public Health System, Mumbai, India, The International Council
on
Management of Population Programme (ICOMP), November 2001
3. Paving the Way for RCH - Tools for Quality and Gender Mainstreaming
4. Training Manual on Women’s Health for Clinicians
5. Training Manual for Health Care Providers on Women Cented Counselling in a
Gynaecology Clinic
6
Stepping Stones Workshopin a Public Health Department
7
increasing Men’s Involvement in Reproductive Health: Experiences of WCHP
Mumbai
8. Counselling Services in the Gynaecology Clinic of a Municipal Hospital in
Mumbai
9. Reproductive and Sexual Health in a Public Health System: Policy Briefs
10 Working With Men - Gender, Rights, Sexuality, Health: Trainer’s Manual
11 Mainstreaming Quality Assurance in the Public Health Department, Mumbai,
India
12. Mainstreaming Gender and Rights in Reproductive Healt Care within a Public
Health System A Review of Women -Centred Health Project, Mumbai
13 C D on Publications of Reproductive and Sexual Health in a Public Health
System
IEC Material Produced
1.
2.
3.
4.
‘Mahiticha Bagicha’ (Wall chart on Reproductive Tract Infections. Marathi)
Pamphlet on RTIs (Hindi and Marathi)
Pamphlet on MTP (Hindi and Marathi)
Pamphlets on ANC (Hindi and Marathi)
For further information, contact:
Training Cell,
IPPV Public Health Department.
First Floor. F South Ward Office
Parel. Mumbai 400 014
Published by
SAHAJ
1, Tejas Apartments
53 Haribhakti Colony,
Old Padra Road,
Vadodara - 390 007
sahajbrc@icenet.co. in
Published in:
February 2006
Supported by:
Ford Foundation
Printed by:
INNOVATORS
Heramb Apartmen
Vadodara - 390 0!
Cover page design:
Amol Thakurdas
Community Health Cell
Library and Information Centre
# 359, "Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Ph : 2553 15 18/2552 5372
e-mail : chc@sochara.org
Women Centred Health Project I Report of the End Evaluation
CONTENTS
SECTION 1
BACKGROUND INFORMATION FOR END EVALUATION
Chapter 1
Introduction
1
Chapter 2
Baseline Studies
9
2.1
Review of health care facilities (1997)
2.2
A study of health care providers’ perceptions and attitudestowards women’s 9
health and quality of care provided by municipal health care facilities (1997)
15
2.3
Exit interviews of users of municipal health services
24
2.4
Observations of client-provider communication at gynaecology out-patient
2.5
clinic of a secondary hospital (1998)
27
Identifying counseling needs of women seeking consultation at
34
gynaecology outpatient clinic at a secondary hospital (1999)
2.6
Review of staff and instruments at health posts and dispensaries (2000)
36
2.7
Exit interviews at gynaecology outpatient clinics at health posts (2001)
39
2.8
Baseline study for counseling center at gynaecology outpatient clinic of a
44
secondary hospital (2001)
Chapter 3
Evaluation
55
SECTION 2
FINDINGS OF END OF THE PROJECT EVALUATION
59
Chapter 4
Evaluation of objective 1: Expansion of Range of Reproductive Health Services
61
Chapter 5
Evaluation of objective 2: Quality Assurance Mechanisms
73
Chapter 6
Evaluation of objective 3: Implementation of Women Friendly and Client Friendly IEC
105
Chapter 7
Evaluation of objective 4: Establishing Monitoring and Evaluation Systems
113
Chapter 8
Evaluation of objective 5: Capacity Building
117
Chapter 9
Evaluation of objective 6 Dissemination and Mainstreaming
135
SECTION 3
SUMMARY OF END OF THE PROJECT EVALUATION
141
Chapter 10
Summary
SECTION 4
REPORT OF EVALUATION OF WCHP
143
ANNEXURES
Annexure 1: Supporting information for baseline studies
184
Annexure 2: Studies for end evaluation
210
Annexure 3: Supporting information for evaluation of objective 1
212
Annexure 4 Supporting information for evaluation of objective 2
225
Annexure 5: Supporting information for evaluation of objective 3
244
Annexure 6: Tools used for baseline studies
249
Annexure 7: Tools used for midterm and end evaluation studies
303
Annexure 8: Plan of midterm evaluation
327
I Women Centred Health Project I Report of the End Evaluation
GLOSSARY OF ABBREVIATIONS
Abhivyakti
Name of an NGO__________________
FTMO
ACASH
Association for Consumers’ Action for
FW & MCH Family Welfare and Mother Child Health
G/N
G/North (One of the 24 administrative
AHO
Assistant Health Officer
Safety and Health_________________
Full Time Medical Officer__________
wards of Mumbai)________________
AGI
Adolescent Girls’ Initiative___________
Gen._____ General________________________
AIDS
Acquired Immuno-Deficiency Syndrome
Govt._____ Government.____________________
AMC
Additional Municipal Commissioner
Gutkha
AMO
Administrative Medical Officer________
GynTGynaec. Gynaecological__________________
ANC
Ante Natal Care
H/E
ANM
Auxiliary Nurse Midwife_____________
Flavoured tobacco________________
H/East (One of the 24 administrative
wards of Mumbai)________________
Ayabai
Health Post Attendant______________
HHs
Households_____________________
BCG
Vaccine against tuberculosis
HIV
Human Immuno-deficiency Virus
BPS
Bachelor in Dental Sciences_________
HPA
BMC
Brihanmumbai Municipal Corporation
Health Post Attendant (addressed as
ayabai)
BP apparatus Blood Pressure apparatus
HP
Health Post
B.Sc.
Hosp.
Hospital
BPL
Bachelor of Science (15 years of education)
Below Poverty Line_________________
Hrs.
Hours__________________________
CBO
Community Based Organisation______
HSC
Higher Secondary Certificate_______
CDO
Community Development Officer
ICPD
CHVs
Community Health Volunteers
International Conference on
Population Development
CME
Continuing Medical Education
IEC
Information Education Communications
CSSM
Child Survival and Safe Motherhood
IPP-V
India Population Project - V________
Programme______________________
ISDT
Integrated Skill Development Training
Cu-T
Copper T_________________________
Jr.MOH
Junior Medical Officer of Health
D. Pharm.
Diploma in Pharmacy
K/E
DEHO
Deputy Executive Health Officer_______
Del.
Delivery
DET/ Det
Dentist__________________________
Disp
Dispensary
PMC
Deputy Municipal Commissioner
KMH
Kherwadi Maternity Home
K/East (One of the 24 administrative
wards of Mumbai)________________
KEM
King Edward VII Memorial Hospital (Larg
est teaching hospital owned by the
Municipal Corporation of Greater Mumbai
DMLT
Diploma in Medical Laboratory Techniques
LB
Live births______________________
DOTS
Directly Observed Treatment Short course
LT______
Laboratory Technician
DPT
Vaccine against diphtheria, pertusis and
M_______ Male___________________________
tetanus__________________________
Mar._____
Marriage________________________
Maternity________________________
Electrocardiogram_________________
Mat.
ED
Expected date_____________________
Mat.Home Maternity Home__________________
EDD
Expected date of delivery____________
Max.
Maximum_______________________
EDL
Essential Drug List
MB
Mahiticha Bagicha - Informative broad-sheet
EHO
Executive Health Officer
ECG
/ wall chart on Reproductive Tract Infection
Bachelorof Medicine and Bachebrof Surgery
EPI
Expanded Programme of Immunisation
MBBS
F___
Female
MC
Municipal Commissioner
FGD
Focus Group Discussion____________
MD
Doctor of Medicine (Post-graduation in
FHAC
FFW
Family Health Awareness Campaign
Female Field Worker_______________
MCGM
Allopathic System of Medicine)______
Municipal Corporation of Greater Mumbai
FP
Family Planning
MDACS
Mumbai District AIDS Control Society
FPAI
Family Planning Association of India
MHADA
Maharashtra Housing and Development
FS__
Ferrous Sulphate
Ft.
Feet
Authority________________________
Ml
Malaria Investigator
| Women Centred Health Project I Report of the End Evaluation
MIS
Minimum_____ ____________________
Management Information System______
MO
Medical Officer______________
MOi/c
Medical Officer In-charge
Min.
SI. No.
Serial Number
____
,
SLM. /Sim. Slum_______________________
Society for Nutrition Education and
SNEHA
Health Action_________________
Special Officer (Family Welfare)_____
MOH
Medical Officer of Health_____________
SOFW
MIC
Men’s Involvement Committee
SPSS
Statistical Package for Social Sciences
MPC
Module Preparation Committee
Square_____________________
MPW
Multipurpose Worker — Male_________ _
SqSr. MO
__
Senior Medical Officer_____________
Secondary School Certificate (10 years
Marital status_____________
Medical Superintendent, Administrative
SSC
Head of General Hospital____________
STD
Sexually Transmitted Disease
Vaccine against measles____________
Std.
Standard_______________________
Standard Treatment Guideline
MTP
Months___________________________
Medical Termination of Pregnancy
STG
STI
Sexually Transmitted Infection
MWD
M. W. Desai Hospital
______________
Tathapi
A NGO based in Pune
____________
NA______ Not Applicable
NK______ Not Known______ ___________ ________
NGONLEP Non-Governmental Organisation National
TB_____
Tuberculosis____________________
TISS
Tata Institute of Social Science
TL_____
Tubal Ligation______
TO____
Treatment Organiser
TOT
Training of Trainers
MS
MS
MSI
Mths.
of education)_________________
Leprosy Eradication Programme
No.
NSV~
Number________________
_
OPP
Out Patient Department_____________
TV
Television
OPV
Oral Polio Vaccine____________
UHC
Urban Health Centre
ORS
Oral Rehydration Solution___________
UK
Paed.
Paediatrics_______________________
UNICEF
United Kingdom
United Nations International Children’s
PC
Patients’ Charter of Rights and
Tetanus Toxoide
Non Scalpel Vasectomy
_ Education Fund____________
_ __
Responsibilities___________________
USG
Ultrasonography________________
UV__
PHD
Public Health Department___________
VCTC
Ultra-violet___________________
Voluntary Counseling and Testing Centre
PHN
Public Health Nurse________________
VitA
PIP
Pelvic Inflammatory Diseases
VNDH
PMP
Private Medical Practitioner
PNC
Post Natal Care___________________
PPC
Post Partum Centre________________
PV____
Per Vaginum
QA____
Quality Assurance______________
WHCs
Women’s Health Centres
World Health Organisation
RCH
Quality of Care
_
Reproductive and Child Health
WHO
WG
Working Group___________ _______
RDU
Rational Drug Use________
Wt.
Weight__________________
RH
Reproductive Health
Lakh
Revised National Tuberculosis Control
Wards
100,000________________________
Administrative units of the MCGM
Programme
KIT
Royal Tropical Institute, Amsterdam
D&C
VOICES
Dilatation and Curretage___________
PHC
QoC
RNTCP
RMO
RS_____
Primary Health Care
_
•_______________
____________________
Resident Medical Officer
RTI
Ranking System
_
Reproductive Tract Infection
SAHAJ
Society for Health Alternatives
SAHYOG
Name of an NGO in UP____________
SB
Still births________________________
SG_____
Support Group____________________
SS_____
Stepping Stones__________________
SHED
An NGO
_ Vitamin A____________________ ___
V. N. Desai Municipal General Hospital
Vaccine Preventable Diseases
VPD
WOHTRAC Women’s Health Training Research
and Advocacy Cell________
Women Centred Health Project
WCHP
Name of an NGO
| Women Centred Health Project"] Report of the End Evaluation
SECTION 1
BACKGROUND INFORMATION FOR
END EVALUATION
I
>'"8.
a
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I Women Centred Health Project I Report of the End Evaluation
Chapter 1
Introduction
Municipal Corporation of Greater Mumbai — Public Health Department
Established in 1865, Municipal Corporation of Greater Mumbai (MCGM) is the civic body that looks after
the metropolis of Mumbai spread over 437.71 square kilometers with a population of 119.4 lacs (2001
census). For administrative purposes Mumbai is divided into 24 wards that are grouped into six zones and
three bureaus. Public health and hygiene services are provided by the Public Health Department of the
MCGM. These include out reach services related to immunisation and contraception through 176 (PHD)
health posts, basic curative services through 162 dispensaries and maternity and child welfare services
through 27 maternity homes and obstetrics and gynaecology departments of 16 peripheral hospitals and
three teaching hospitals. Other activities of the PHD include registration of births and deaths, regulation
of places for the disposal of the dead, school health services, control of communicable diseases, food
sanitation and prevention of adulteration of food and other services. The PHD is headed by Executive
Health Officer. Detailed structure of the PHD is presented in Exhibit 1.
In the past years MCGM has shown its openness to newer perspectives and newer programmes that
would increase its efficiency to reach out to the most needy. Piloting of Revised National Tuberculosis
Control Programme (RNTCP), implementation of India Population Project - V (IPP-V) etc., and various
small interventions are examples to this.
Women Centred Health Project
Women Centred Health Project (WCHP) was developed as an action research project to demonstrate
feasibility of expanding the range and improving the quality of reproductive health services provided by the
Public Health Department (PHD) of the Municipal Corporation of Greater Mumbai (MCGM). The project
was a collaboration of PHD of MCGM, Society for Health Alternatives (SAHAJ) — a non-governmental
organisation based in Vadodara, Gujarat and an academic institution Royal Tropical Institute (KIT),
Amsterdam. Each of the three collaborators brought along different perspectives that strengthened the
ability of the project (Exhibit 2). Uniqueness of the project lied in its being a collaboration of three different
organisations and being placed within the hierarchy of the PHD. This also made the project’s experiences
of great value to all those desirous of working on gender and quality issues within the public health
systems.
I
1
I
Exhibit 1: Structure of Public Health Department of the Municipal Corporation of Greater Mumbai
Municipal Commissioner
o
2
Additional Municipal Commissioner
2
Joint Municipal Commissioner (Medical Education and Health)/Deputy Municipal Commissioner
I
I
Executive Health Officer
I___________
Deans (Teaching Hospital)(3)
I
M.S. Peripheral Hosp. (16)
X
CD
J
Chief Med. Superintendent
(i/c Peripheral Hospitals)
M.S. (Spl. Hosp.)
K>
~
IP
Joint Health Officer
<0
o’
'
DEHO
(FW & MCH)
DEHO
(TB)
DEHO
(Cells)
DEHO
(HQ)
o
DEHO
(Zones 1 to VI)
I
I
;
AHO
(Schools) i
_____
‘
AHO
(Bureaus)
| AHO I I
(EPI)
I-----MS&
Training
I
I
I !
I
AHO
(IEC)
AHO
(Epdt)
AHO
(Surv.)
AHO
(TB)
AHO
(Office)
J____
CD
AHO
(Zones)
o
o
CD
rn
—‘
Maternity Homes
I
Post Partum Centre
i
MOH
I
CDO
m
2L
c
o
Dispensaries
Health posts
Birth & Death
Registration
Registration of
food establishment
Maharashtra-Preventior
of food adulteration act
Epidemic
control
Nursing homes
registration
Regulation of
PNDTAct
| Women Centred Health Project I Report of the End Evaluation
Exhibit 2: Women Centred Health Project
SAHAJ
Roles:
•
18 years of experience in promoting holistic
and women-centred health care
>
•
•
Provides managerial inputs to WCHP
Vision and perspective-building
Strengths:
•
High motivation and social commitment
•
Sensitivity to need of the marginalized
•
Relevant experience
•
Access to information, expertise, materials
related to other groups in India and the region
•
Flexibility and innovativeness
•
Thorough networking, enable exposure to
other projects and dissemination of learnings
from WCHP
KIT
PHD, MCGM
Roles:
•
Experience in providing education,
Roles:
•
Implementation
•
Provide
human
resource
training, and consultation services on
and
behalf of aid agencies
infrastructure through 3-tier health care
•
•
delivery system network of health posts,
dispensaries, maternity homes, 16
Technical inputs to WCHP
Contribution to monitoring, planning and
evaluation in WCHP
peripheral hospitals, 3 teaching and 5
special hospitals
•
Lrgest provider of health care in public
Strengths:
sector in Mumbai
•
•
Strengths:
•
•
Infrastructure
•
•
Wide reach
Policy-makers can influence people’s
Technical expertise
Sharing experiences, programmes and
activities in other countries
Making resources accessible (training
manuals, research documents)
•
Capacity building through workshops
lives through services and programmes
>
4-
3
1
| Women Centred Health Project I Report of the End Evaluation
Origin of the Women Centred Health Project (WCHP)
Over a period of three years from 1993 to 1996 a research study was conducted jointly by the MCGM and
the Women’s Health Group from Liverpool School of Tropical Medicine to investigate the clinical and
social aspects of Pelvic Inflammatory Disease (PID). Detailed social, clinical and microbiological data
was collected from over 3000 women. A sub-sample of 200 (of these 3000) were interviewed in depth
about the consequences of the reproductive health problems and circumstances in which these problems
occurred. Thirty auxiliary nurse midwives (ANMs) were involved in the study. An ongoing training programme
for the ANMs was developed to enhance their ability to communicate with women about their sexual and
reproductive health problems and to conduct structured and semi-structured interviews. Through the
interviews the ANMs developed an insight in the need for service improvements to address women’s
health needs.
Problems identified through PID study were related to -
•
lack of appropriate and accessible information, counseling and support services;
•
•
treatment and referral services provided;
decision making power of women in family which limits their control over their reproductive health.
Qualitative data from the semi-structured interviews, together with preliminary results of the large quantitative
survey identified entry points for the development of a health intervention programme. Through discussions
with the policy makers about the findings from the PID study and areas in need for improvement broad
agreement was reached to implement activities in response to the needs emerging from the PID study.
Women Centred Health Project was developed to operationalise the learnings from the PID study.
The objectives of the Women Centred Health Project were
1. To implement select reproductive health services at the level of health post, dispensary and post
partum centre (PPC) by
• increasing range of services on prioritised health problems
2.
• involving men
To establish and implement quality assurance mechanisms including communication, treatment and
3.
referral procedures.
To implement women friendly and client friendly IEC by
4.
•
developing material with participation of clients
•
training of staff using these
•
creating links between the IEC Cell of the BMC and the project
To establish monitoring and evaluation systems by
•
•
implementing supportive supervision system
establishing systems for process evaluation of training, quality assurance, ability to meet women s
•
information and support needs
establishing system for measuring effects of interventions on attitudes and practices of the health
care providers, perceptions about quality of services of the users, indicators of quality of care,
•
indicators on efficiency and effectiveness of services
measuring cost efficiency of all primary care services with special emphasis on selected
reproductive health services
I
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j Women Centred Health Project I Report of the End Evaluation
5.
6.
Through all activities, build capacity of staff in two wards and of the PHD of MCGM regarding
•
training
•
action research
•
•
monitoring and evaluation
information, education and communication (IEC) skills and regarding the process of preparation of material
•
treatment and referral for selected reproductive health conditions
•
training modules integrated into ANMs’, MPWs’, FTMOs’ training programmes
•
establishing a research cell in the MCGM
To disseminate and mainstream learnings from the project by
•
creating structures within the project, i.e. committees and sub-committees
•
relating with other programmes
•
up-scaling of selected interventions
Box 1.1: Issues that WCHP aimed to address
Information needs
•
Knowledge to women about functioning of their bodies, how contraceptives work, symptoms and
transmission of STIs and RTIs, and what to expect when undergoing MTP, sterilisaiton and D&Cs.
Treatment and support needs
•
Address long waiting times at out patient departments of secondary hospitals, changing
consultants, insufficient information on diagnosis, treatment and effects of treatment, confusing
referrals and being treated with disrespect.
•
Address women’s anxiety about inability to conceive, isolation and desperation faced by
childless women.
•
Information about causes of infertility, possible treatment and support services for adoption
and counseling.
Service provision and training needs
•
Effect change in population control oriented services, limited choice of contraceptives, change
focus on mobilising women to be acceptors of contraceptives rather than on giving information,
education and counseling based on reproductive needs identified by women themselves.
Scope of the project — Area, population, health care facilities and health care providers
Women Centred Health Project came into existence in 1996 as a pilot project. The project was to be
implemented in two of the 24 administrative wards of the MCGM, namely H/E and G/N (referred in this
document as the project wards). As mentioned earlier, WCHP was designed as an action research
project to address the information, treatment and support needs related to reproductive and sexual health
of women using the health posts, maternity homes and post partum centres. The goal of the project was
to improve the provision of women-centred health care with an emphasis on sexual and reproductive
health in the MCGM.
5
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I Women Centred Health Project I Report of the End Evaluation
Box 1.2: Profile of the project wards
H/E
G/N
Population (2001 census)
5,25,873
6,40,509
Health Posts
8
9
Dispensaries
6
10
Maternity homes
1
1
Post Partum Centres
1
1
Secondary general hospital
1
Main interventions
The project addressed the issue of expansion of range of reproductive health services at the primary level
by initiating gynaecology clinics at select health posts and dispensaries. Client centred interactive I EC
material developed by the project and counselling and information centre established at the gynaecology
OPD at V N Desai Municipal General Hospital (VNDH) meet the unmet information needs of clients
seeking services for gynaecological conditions. Sustainability of the successful initiatives beyond the
duration of the project has always been a concern of the project. Through a strong capacity building
component WCHP gave inputs on a number of relevant topics for sensitising health care providers to the
concepts of gender, and client centredness which eventually lead to improvement in quality of care from
clients’ perspective.
Box 1.3: Main interventions by WCHP
•
Expanding range of services by initiating gynaecology services at the level of health posts
and dispensaries
•
Initiating a counselling centre at gynaecology OPD of a municipal secondary hospital
•
Capacity building of health care providers for provision of gender sensitive and client
friendly health care and for sustainability of initiatives by WCHP
•
Development of gender sensitive and client centred interactive I EC
Action research consists of an ongoing cycle of assessing needs and identification of problems,
implementation of interventions, monitoring and evaluations. This continuous process then leads to the
identification of areas for improvement, to adaptation of existing interventions and to implementation of
new interventions. To meet the stated goal the project focused on capacity building, development and
implementation of test interventions, and establishing links with PHD of MCGM. Key interventions
introduced by the project on pilot basis were
1.
Perspective building and skill development through training
2.
Expanding gynaecological services at the primary level (gynaecology clinics at health posts)
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"" I Women Centred Health Project I Report of the End Evaluation
3
Improving quality of client-provider communication, ensuring clients’ rights and offering counseling
services to women and their men partners
4.
Development of interactive, gender sensitive and client-centred IEC material
5.
Working with men to increase men’s responsibility in reproductive health
A series of baseline studies formed the basis of these interventions. Comparison of outcomes of interventions
with findings from baseline studies helped WCHP monitor the direction and effectiveness of its interventions.
Approach and strategies
The project enjoyed an unique position because of its being a partnership between the Municipal Corporation
of Greater Mumbai and a non-governmental organisation and an academic institution. The project followed
a participatory approach to ensure ownership of the test interventions. Chief strategy was to demonstrate
feasibility of various interventions for expanding the range of reproductive health services and improving
the quality of these services from women’s perspective. Models that could be replicated within the MCGM
with mobilisation / reorganisation of available resources were created. The project focused on capacity
building of the health care providers and on creating a conducive environment within the PHD for the
changes proposed by the project by establishing committees and sub-committees and by introducing
monitoring and evaluation mechanisms. This shaped WCHP as an action research project.
Structure of this report
The report is divided into four sections. First section covers introduction to the project , the baseline
studies and the rationale for end evaluation. Each of the six objectives of the project is evaluated in
section two. Key issues emerging from end evaluation are presented in section three. A review of the
project by an international expert is presented in section four. Issues presented throughout the report are
supported by relevant data. Tools used for evaluation and additional data are presented in annexures.
7
| Women Centred Health Project I Report of the End Evaluation
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Women Centred Health Project I Report of the End Evaluation
Chapter 2
Baselines Studies
Women Centred Health Project began in 1996 with a few background studies to explore the lacunae in
the health care delivery system and also people’s expectations from the municipal health care delivery
system. A study was conducted to document time spent by women seeking care from health posts,
maternity homes and a teaching hospital. Focus group discussions were conducted with men, women
and adolescent boys and girls from the community to explore their health needs and their perceptions
about municipal health care services. Background studies set the direction for the baseline studies,
findings of which shaped the interventions initiated by the project.
Baseline studies
In the initial phases, discussions among the WCHP team about the future shape of the project lead the.
team to undertake three baseline studies that would help identify the issues for intervention and to document
the status of various parameters related to the municipal health care system. These were
1.
2.
Study of health care providers’ perceptions of and attitude towards women’s reproductive health
3.
Client satisfaction study
Review of health care facilities
Findings of these studies were crucial in developing strategies and identifying entry points for the project.
Over the years as the project evolved, a number of small studies were conducted that served as baselines
for specific interventions of the project. These were
4.
Monitoring client-provider communication at gynaecology outpatient clinic of a secondary hospital
5.
Identifying counselling needs of women seeking consultation at gynaecology outpatient clinic at a
secondary hospital
6.
Review of staff, equipment and instruments at health posts and dispensaries
7.
Exit interviews at gynaecology outpatient clinics at health posts
8.
Baseline study for counselling centre at gynaecology outpatient clinic of a secondary hospital
Summary of each of these eight studies is presented in this chapter.
2.1.
Review of health care facilities (1997)
Conducted between April to December 1997, this study aimed at assessing quality of municipal health
infrastructure with an objective of identifying areas that needed to be strengthened to ensure quality
reproductive health services. Objectives of this study were
To document
9
the existing infrastructure of the health care facilities
6
types of health care services provided by the health care facilities
available human resource, drugs, equipment and medical supplies
mechanisms adopted for ensuring continuity of care, including mechanisms for Management
Information System (MIS) and monitoring mechanisms
®
work-load of health care providers in terms of outpatient care
L
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| Women Centred Health Project I Report of the End Evaluation
Methodology
Study area and sample
■
J
Twelve health posts, nine dispensaries, and two post partum centres from H/E and G/N wards formed the
sample for the facility study. Sample facilities were selected from those that catered to a predominantly
slum or slum-like area and those that catered to a mixed population of slum or slum-like and non-slum area.
Tools
A proforma for recording details of each of the sample facilities was used for data collection. The tool for
data collection was developed in consultation with the project ANMs trained in research skills during the
RID project who were entrusted with data collection for this study. Tool was pre-tested by one team
member of WCHP and one project ANM. (T-6.1 Annexure 6)
-‘’S •
c
Data collection
Ten project AN Ms were involved in data collection. Prior to data collection the investigators were oriented
to the tool and trained in data collection. Data were collected over a period of five months ranging from
May to September 1997. Quantitative data collected by investigators were checked by project team and
analysed using LOTUS.
h
Table 2.1: Sample for the facility study
Health care facilities included in the study___________________
H/E
G/N
Health posts attached to either dispensary or maternity home / RPC
4
4
Stand alone health posts
2
2
Dispensaries
4
5
Post Partum Centre (PPC)
1
1
Findings
Physical structure
w-
Health posts
Four of the 12 selected health posts were ‘stand alone’ and the rest were housed either within the
dispensary or the maternity home. These health posts varied widely in availability of space and privacy.
Floor space assigned to the health posts varied from 100 square feet to 964 square feet with an average
of 505 square feet. Number of rooms ranged from one to four. Six of the 12 health posts had separate
examination room and three had separate room for storage. Three of the 12 did not have attached toilets
and in one health post that had two toilets attached to it, the toilets were not cleaned daily. Three health posts
did not have running water for 24 hours. One of the 12 health posts did not have electricity. (Table 1A Annexure 1)
Two of the 12 health sample posts did not have a compound wall that plays important role in cleanliness
of the external premise of the health posts especially those located in the slum area.
•u'
Dispensaries
Four of the nine dispensaries were stand alone and the rest were housed with health posts. Number of
rooms available to these dispensaries ranged from two to 11 and area varied from 144 square feet to 4000
square feet. Four dispensaries did not have separate examination room, two of these dispensaries were
housed in structures with eight and five rooms. All dispensaries had separate storage area. All except
one facility had more than one toilets and in most places these were cleaned daily. Three of the nine
k *
dispensaries had regular water supply. (Table 1B Annexure 1)
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| Women Centred Health Project I Report of the End Evaluation
PostPartum Centres (PPCs)
Post Partum Centres were housed in the same buildings as the maternity homes. Floor space was 300
to 350 square feet. Both PPCs had attached toilets with adequate running water although one was not
cleaned daily . Both PPCs did not have a separate examination room. (Table 1C Annexure 1)
Services provided through health care facilities
Health posts
Health posts were established in 1988 under the India Population Project - V to provide outreach services
related to immunisation, family planning, ante-natal and post-natal care and health education. Baseline
survey by WCHP documented services provided through the health posts to explore whether the health
posts were meeting their set objectives a decade after they were established.
Box 2.1: Functions of Health Posts : IPP-V guidelines
Out-patient clinics
• Treatment to patients referred from field by health care workers
• Referral, if required, to general or infectious disease hospital as the case may be
• Attending to persons seeking family planning advice and follow up
• Conducting immunisation sessions
• Conducting ANC / PNC clinics, gynaecology / obsterics OPDs in case of hospitals and
maternity homes
Family planning services
• Sterilisation (vasectomy and tubal ligation)
• IUCD insertion
•
•
•
Distribution of condoms
Medical termination of pregnancy (MTP)
Distribution of oral pills
Communication and health education
• Advice on MCH and FP to the mothers visiting the health post
• Arranging and conducting group talks on MCH, FP, Immunisation and other health related topics
Planning and organisation
• Planning and organising family planning camps
• Planning and organising immunisation sessions
• Organising exhibitions on ORS, nutrition, family planning, and immunisation
Activities in the field
• Meeting the community
• Camps and sessions
Health education
Other activities
• Growth monitoring
• Disease surveillance for TB, leprosy, malaria
• Identifying eligible couples and motivating them for family planning
(Delivery of care to Mothers and Children in Outreach Service Area, A document prepared by Dr.
(Mrs.) Vinodini Desai, Executive Health Officer and Dr. G. T. Ambe, Assistant Health Officer,
Municipal Corporation of Greater Mumbai, 1995)
11
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| Women Centred Health Project I Report of the End Evaluation
Immunisation and family planning services were the only ones that all 12 health posts reported to be
providing. Six health posts provided curative out patient care which actually is beyond the call of the
health posts. ANC and PNC services were being provided by seven and five health posts respectively.
(Table 2A Annexure 1) The facility survey was conducted during the pilot phase for RNTCP in Mumbai.
One of the wards included in the facility survey was involved in this pilot phase. Hence five of the 12 health
posts included in the survey reported providing treatment for TB.
Dispensaries
Provision of curative care is the primary function of the dispensaries. All dispensaries provide immunisation
services. Upgraded dispensaries run a dental clinic and pathology laboratory services. Two dispensaries
from the sample provided dental services and two had pathology laboratories attached to them. All nine
dispensaries reported to have conducted general OPD and six of the nine dispensaries reported to have
provided immunisation services. (Table 2B Annexure 1)
PostPartum Centre
Post Partum Centres primarily provide temporary contraceptives and paediatric services. In addition,
PPG in H/E provided ANC, sonography and blood investigations. PPC in G/N ward had a PNC and well
woman clinic. PPC staff carried out health education sessions on topics related to ANC, child care,
immunisation, breast feeding and family planning. The PPCs did not provide permanent methods of
contraception, medical termination of pregnancy and immunisation. Clients in need of services other
than those provided by the PPC were either referred to the adjacent maternity home or nearby peripheral
hospital. (Table 2C Annexure 1)
Human resource
Health posts
As per the IPP-V norms the health posts are required to have one full time medical officer (FTMO), one
public health nurse (PHN), four to five auxiliary nurse midwives, three to four male multipurpose workers
(MPW), 25 community health volunteers (CHV), one clerk and one health post attendant (HPA). The
study found that in two of the 12 health posts surveyed positions of FTMO were vacant. Both these health
posts catered to predominantly slum population and were not ‘stand-alone’1.
In one of the ‘stand-alone’ health posts position of PHN was not filled. This health post served a
predominantly slum population.
The norm of four to five ANMs per health post was met only by four of the 12 health posts included in the
survey. In one health post all posts of ANMs were vacant. Three health posts had one ANM each. Two of
these health posts were not ‘stand alone’ and catered to a mix of slum and non-slum population. One
health post with one ANM was a ‘stand alone’ one, catered to predominantly slum population and had a
vacant post of PHN. Three health posts had two ANMs. One of these three served the slum population
and did not have a FTMO. None of these three were ‘stand alone’ health posts.
Five of the 12 health posts had three or four MPWs. Rest had one or two. All the health posts reported
having a health post attendant. One of the health posts had two health post attendants. (Table 3A Annexure 1)
1 Stand alone : Some of the health posts are housed in the same premise as the dispensaries or hospitals whereas some are
situated in separate structures. Health posts situated in separate structures are referred to as ‘stand alone’ health posts.
When health post and dispensary are located in the same premise, there is more coordination and cooperation between the
staff of the health post and the dispensary.'
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| Women Centred Health Project I Report of the End Evaluation
Dispensaries
Dispensaries are managed by a team of a medical officer (MO i/c), a pharmacist, a dresser and an
attendant and/or a sweeper. In addition to these, upgraded dispensaries have laboratory technicians,
laboratory assistants and dentists. Other staff specific to services provided through some health pojts
are malaria investigators and treatment organisers for following up defaulter TB patients. Of the nine
dispensaries included in the sample one had a vacant position of medical officer.Five of the surveyed
dispensaries did not have sweeper in place and in two dispensaies the post of attendant was vacant.
(Table 3B Annexure 1)
PostPartum Centres
Post Partum Centres were established under the India Population Project - V in 1988. As per the norms
of the IPP-V, each (PPG) is required to have one medical officer (obstetrics and gynaecology), one
medical officer (paediatrics), two auxiliary nurse midwives, one multi-purpose worker and one clerk.
One PPG included in the survey had one vacant position of ANM and the other had a vacancy for MPW.
(Table 3C Annexure 1)
Details of gender and qualification of the staff at health posts, and dispensaries included in the study are
presented in Tables 4A, and 4B in Annexure 1.
Utilisation of services
Health posts
Immunisation: Data on number of clients served through centre and through area camps was obtained for
the week prior to data collection. Seven out of 12 health posts had conducted area camps in this period.
Reasons for not conducting area camps were vacant position of FTMO and FTMO being busy with
cleanliness campaign. Of the five health posts that did not have area camp, in two health posts immunisation
had not been offered even at the facility in the week prior to data.collection. (Table 5A Annexure 1)
Dispensaries
Data on utilisation of out patient clinics of the sample dispensaries for the week preceding the survey
were obtained. Weekly utilisation ranged from 86 to 794 i.e. on average dispensaries offered services to
14 to 132 clients per day. (Table 5B Annexure 1)
PostPartum Centre
563 clients had availed of services at one of the PPCs included in the study over the week preceding the
survey. Average daily utilisation for this PPG came to 94. Data for other PPG was not available. (Table 50
Annexure 1)
Maintaining records
Health posts
Maintaining records was reported to be an important activity that took up large portion of work hours of
the health care providers. The facility survey found that health posts maintained around 54 different
registers. (Table 6A Annexure 1)
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Women Centred Health Project I Report of the End Evaluation
Dispensaries
Dispensaries maintained around 24 different registers. (Table 6B Annexure 1)
PostPartum Centres
One RPC reported maintaining 14 registers while the other one maintained 27 registers. (Table 6C Annexure 1)
Equipment
Health posts
In light of the main objective of setting up health posts which was to provide contraceptives, immunisation,
ANC, PNC and immunisation at the doorstep of the people, non availability of stethoscopes, instruments
for measurement of blood pressure, weighing scale, sterilisers/autoclaves, speculum etc. is significant.
Less than satisfactory performance of the health care facilities thus needs to be studied in light of non
availability of essential equipment and inadequate human resources. (Table 7A Annexure 1)
Dispensaries
Eight of the nine dispensaries studied had basic equipment like stethoscope, BP instrument and steriliser.
Except one dispensary that had speculum and vulselum, others were not equipped to conduct gynaecological
examination. (Table 7B Annexure 1)
PostPartum Centres
Both the PPCs had equipment required for gynaecological examination.. (Table 7C Annexure 1)
Drugs
Health posts
Health posts being the outreach units are provided with a restricted number of drugs and medicines.
Availability of drugs (e.g. Doxycycline, Cotrimaxazole, vaginal pessaries, Flagyl etc.) required for treatment
of reproductive tract infections was found to be unsatisfactory. Less than half the number of health posts
included in the study reported a stock of these drugs. Seven of the twelve health posts included in the
study had the stock of iron folic acid tablets. (Table 8A Annexure 1)
Dispensaries
Most of the dispensaries were equipped to treat ailments such as fever, malaria, worms and minor injuries.
However except for Flagyl that was available with eight dispensaries, dispensaries appeared poorly
equipped to treat gynaecological conditions. (Table 8B Annexure 1)
PostPartum Centres
Drugs and medicines required for management of gynaecological conditions were not available at one of
the PPCs. (Table 8C Annexure 1)
Monitoring of health care facilities
None of the health posts, dispensaries and PPCs had a system of regular staff meetings for review of
progress and problem solving purposes. None of the facilities reported a staff meeting in the month
preceding the survey.
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| Women Centred Health Project I Report of the End Evaluation
Box 2.2: Key issues identified through the facility study
•
Health posts and dispensaries were inadequately equipped to treat gynaecological conditions.
Many facilities lacked adequate measures for ensuring privacy, equipment required for
examination and drugs required for treatment of common gynaecological conditions.
Strengthening the health posts and dispensaries in terms of infrastructure is the first step for
expanding the range of services to include reproductive health services.
Staff at many health posts is not as per the IPP-V norms. Vacant positions of out reach
workers in health posts catering to slum population will affect quality of outreach services.
Non availability of FTMO and PHN in health posts serving predominantly slum population will
hamper the provision of services defined by the IPP-V.
•
As reported by the staff, maintaining large number of registers takes up valuable time that
could be better spent in outreach services. There is a need for streamlining of MIS.
2.2. A study of health care providers’ perceptions and attitudes towards
women’s health and quality of care provided by the municipal health care facilities
WCHP aimed to expand the range of services provided through the primary level municipal health care
facilities to include reproductive and sexual health care and to improve the quality of reproductive health
services provided through municipal facilities. Attitude of health care providers towards ‘reproductive and
sexual health’ and social attributes of sexual and reproductive health conditions, play a key role in
determining quality of reproductive health services. Interventions for incorporating reproductive and sexual
health services into those provided through the primary level municipal facilities and improving quality of
RH services can only be successful if they address specific areas that need strengthening. It was believed
that developing a perspective conducive for provision of women friendly, gender sensitive reproductive
health care among the providers, would convince them about necessity of modifications in the services
and lead to action. An exploratory study was therefore carried out in two project wards to explore perceptions
and attitudes of health care providers towards factors affecting the quality of care in general and women’s
health in particular.
Objectives of this study were
•
To explore
- health care providers’ perception and attitude towards women’s health
-
health care providers’ perception and attitude towards quality of care
-
problems faced by the health care providers in providing services and their suggestions for
addressing the problems
-
health care providers’ views / ideas for improving quality of municipal health care services
-
training needs of health care providers
-
To document time spent on execution of each of the responsibilities listed in the job chart
15
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| Women Centred Health Project I Report of the End Evaluation
Methodology
Study area and sample
The study was carried out in project wards (H/E and G/N). Of the total 30 health care facilities from these
two wards, 13 were purposively selected. A sample of health care providers from each of the health care
facilities was identified and included in the study. A pilot study was carried out using the same tool that
was used for the final study. Results of this pilot study were used to determine the sample size for the
study. Since there were little variation in responses of providers within each category and also between
various categories, a small sample size was decided on. Proportion of health care providers that come in
contact with ailments more frequently than others (doctors, public health nurses, nurses from maternity
home/hospital, auxiliary nurse midwives, community health volunteers) was higher than that of other categories
(dresser, pharmacist, labourer, laboratory technician, treatment organiser etc.). Tool used for the survey is
presented in Annexure 6 (T-6.2 Annexure 6). Details of the sample are presented in following table.
Table 2.2: Health care providers interviewed
Health post Dispensary Post Centre
Partum
Health care provider
15
2
3
2
7
5
4
1
1
10
2. Public health nurse/ nurse
2
5
3
5
1
12
12
6. Pharmacist
7. Treatment organiser
Hospital
4
3
4. Multipurpose worker
5. Community health volunteer
Home
Total
1
1. Medical officer
3. Auxiliary Nurse Midwife
Maternity General
4
4
1
2
1
1
8. Laboratory technician
9. Clerk
3
10. Attendant
2
1
5
2
2
11. Dresser
4
4
12. Labourer
3
3
TOTAL
32
8
17
6
7
70
Tool
A questionnaire developed with the participation of 15 health care providers and pre-tested for each category of
health care provider, was used for data collection. The questionnaire used for the study is included as Tool 1.1.
Box 2.3: Topics covered in the questionnaire
Background of health care provider
Job responsibilities
Perception of women’s health
Attitude towards women’s health
Perception of quality of municipal health care services
Attitude towards quality of care provided by municipal health care facilities
Problems faced in health care delivery
Perceptions of referral system
Perception of out reach services
Training needs
Perception of constituents of ‘good health care’
Suggestions for improving the quality of municipal health care services
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| Women Centred Health Project I Report of the End Evaluation
Data collection
The medical officers were asked to fill in the questionnaires after the objectives of the study were explained
and consent was sought from them. The WCHP team interviewed other health care providers. Prior to
data collection, oral consent was sought from all health care providers after the objectives of the study
were explained to them. The questionnaire did not require the respondents to reveal their name or any
other identifying information and thus ensured confidentiality. Data was collected over six weeks spanning
over November - December 1997. Quantitative data was coded and analysed manually.
Limitations of the study
All information in this study was as reported by the health care providers. None of the information including
factual information related to demographic variables was verified against available sources. Data on attitudes
and perceptions was gathered through an agree/ disagree exercise. The responses for these exercises
were not probed / discussed. Familiarity of the health care providers with the project team might have
resulted in courtesy bias (responses favouring the project). The data therefore can not be generalised to
all municipal health care providers. The study was strictly an exploratory study.
Findings
Profile of the respondents
Health care providers included in the study formed a heterogeneous group with wide variations over
categories and within each category. 11 out of 15 doctors were female doctors. The providers had varied
years of experience in the municipal service with minimum of six months (CHV) to 30 years (medical
officers). Number of years of work experience is relevant to knowledge about the system and willingness
of the individual to initiate and absorb new changes. Data showed that 11 out of 15 doctors had spent less
than five years at the present post (facility) whereas larger proportion of the support staff had been posted
at the same facility for five or more than five years. (Table 9 Annexure 1) This information has implications
while developing interventions that envisage medical officers as leaders of the team.
Educational profile of the providers is presented in Table 10 Annexure 1.
Perception about and attitude towards women’s health
Most commonly reported conditions
Health care providers were asked to list six most common health conditions with which women came to
their facilities. The health conditions reported among the six most common conditions for which women
seek help, varied over facilities and over male and female providers. Women health care providers were
more able to report the common conditions for which women sought help at the facilities. They appeared
to be more sensitive to women’s reproductive health problems than men. Women health care providers
could give more detailed (170 responses from 49 women health care providers) lists of conditions for
which women seek treatment rather than men health providers (44 responses from 21 men health care
providers).
Women health care providers reported weakness, vaginal discharge, and gynaecological problems as
the most commonly reported conditions by women. According to the male health care providers, women
mostly sought treatment for gynaecological problems, minor ailments and vaginal discharge. Male health
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| Women Centred Health Project I Report of the End Evaluation
Factors preventing women from being healthy
Ranking of responses by men and women health care providers to this question showed clear variation.
*
More men than women reported ‘general factors’ such as ‘environment and non-literacy’ being responsible
for preventing women from being healthy. (Table 2.4) Most commonly reported reason by women health
f
care providers were ‘too many children’ (27out of 49), ‘malnutrition’ (29 out of 49). These results indicate
a difference in attitude of men and women health care providers towards social factors contributing to poor
I*
i. *■
health of women.
Table 2.4: Providers’ perception of factors preventing wpmen from being healthy
<■
* .
>
t
J
Total
Factors preventing women from being healthy
n=21
n=49
4
8
Malnutrition
3
29
Illiteracy
9
Too many children
7
5
27
Ignorance
4
Lack of personal hygiene
2
5
12
2
5
1
7
Gynaecological problems
1
3
Can not say_______ _________
3
1
Environmental
Women over burdened with work
Domestic problems
i-,
Female
Poverty
Self neglect
.T
Male
Social stigma
•
Poor health services
3
15
5
12
13
2
2
Perceptions about and attitude towards quality of care
Constituents of quality of care
Health care providers were asked to list the constituents of good quality health care (Table 2.5). It was
observed that the constituents listed by providers varied over health facilities and appeared to be related
to problems faced by the health care providers in service delivery. For example, most reported (17 out of
ir
49) constituent of quality of care by health care providers from health posts and dispensaries that face
drug shortage is ‘availability of adequate quantity of drugs’. It is important to note that 'patient satisfaction’
has been mentioned as an important constituent of quality of care by providers from all facilities. (Providers’
perceptions of quality of care by health care facility are presented in Table 14 Annexure 1)
4 .
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| Women Centred Health Project I Report of the End Evaluation
Table 2.5: Constituents of quality of care
Constituents of good quality health care
Total
n=70
Adequate quantity of drugs
17
Patient satisfaction
16
Proper examination
14
All services available
13
Good staff behaviour
12
Quick services
8
Competent doctors
6
Good quality medicines
3
Others
12
Suggestions for improvement in quality of care
Suggestions for improvement can be broadly categorised into (1 )those related to infrastructure, (2) those
placing the responsibility of improving quality of care with clients and (3) those indicating an active role of
providers in improving quality of care (Table 2.6). Two suggestions common to all facilities were ‘ensuring
adequate drugs supply’ (24 out of 70) and ‘health education’ (11 out of 70). 12 out of 70 providers have
mentioned ‘good staff behaviour ‘ as a constituent of quality of care, and three providers have mentioned
‘improvement in staff behaviour ’while listing suggestions for improving quality of care. This discrepancy
points towards the general denial on part of providers of any responsibility for improvement in quality of
care. Facilitywise distribution is presented in Table 15 Annexure 1.
Table 2.6: Suggestions for improvement in quality of health care
Suggestions
Suggestions
Total
Total
n=70
n=70
Related to infrastructure
Providers’ responsibility
Availability of drugs
24
Improve staff behaviour
3
All services should be available
7
Adequate staff
4
Gynaecological services
7
Availability of doctor
3
Investigation facilities
6
Availability of equipment
3
24 hour service
5
Separate examination room
3
Availability of lady doctor
5
Paediatric services
2
Responsibility placed on patients
Health education
11
Create awareness of services
4
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| Women Centred Health Project I Report of the End Evaluation
Quality of municipal health care
In addition to the open-ended questions, providers were asked to mark ‘fully agree’, partially agree,
‘cannot say’, ‘partially disagree’ and ‘fully disagree’ for a list of statements. This exercise was aimed at
eliciting attitude of the providers towards the key issues of women’s health and quality of care.
Statement
Table 2.7: Responses to statements — a reflection of attitudes
Number of health care
providers (n=70)
Quality of care
1. There is a need for improving quality of municipal health care services
Agree - fully or partially (63 %)
2. Training is needed to improve quality of care
Agree - fully or partially (63 %)
3. Staff satisfaction is crucial for good quality of care
Agree —fully or partially (59 %)
4. Quality of municipal health care services is good
Agree - fully or partially (51 %)
5. Users will always complain about quality of services
Agree - fully or partially (49 %)
6. Staff are adequately trained to improve quality of care
Agree - fully or partially (28 %)
7. Quality of municipal health care services can not be improved
Agree - fully or partially (16 %)
The process of improving quality of care starts with acknowledging that there is a need for improvement
and that it can be achieved by a number of ways and by involvement of the team. 63% of respondents
believed that there was need for improvement of quality of municipal health care services. 63% felt that
training was needed to bring about improvement in quality of care provided through municipal health care
services. 59% believed that staff satisfaction was necessary for quality of care. It is interesting to note
that at the same time, a group of the respondents believed that quality of municipal health care services
can not be improved (16%), that staff were adequately trained to improve quality of care (28%), and that
users will always complain about quality of care. Heterogeneous nature of the group is a cause for
concern. Denial of need to improve quality of care and of need for capacity building of health care providers
and disregard for clients’ perception of quality as reflected through response to clients will always complain
about quality of care, hints about the denial of responsibility of health care providers towards improving
quality of care.
Scores were assigned to responses to the statements and average scores were calculated for each
category of providers. This exercise gave an idea about the extent of positivity of attitude of each category
of providers.
It is interesting to note that while more than three fourth of the 70 health care providers agreed that women
have more health problems, that women have difficulty protecting themselves from the sexually transmitted
diseases, and that men should take more responsibility for contraception use; almost half the providers
were of the opinion that women suffer more health problems because they are ignorant about their health
needs. A large proportion of the providers also have failed to link gender issues with health problems of women.
Details are presented in Table 16 Annexure 1.
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| Women Centred Health Project I Report of the End Evaluation
Problems faced during service delivery and suggestions
The problems listed by providers are mostly related to infrastructure, the most commonly reported being
staff shortage (25 out of 70), insufficient space (24 out of 70) and inadequate furniture (23 out of 70). The
responses also elicited personnel problems such as lack of cooperation and coordination between staff
and unsatisfactory inter-personal relations (9 out of 70).
Along with suggestions for addressing the infrastructure related problems, the responses included need
for supportive supervision ‘prompt measures to solve problems’ (8 out of 70) and ‘increased community
participation’ (4 out of 70).
Training needs
Health care providers included in the study were asked to list down training programmes that they had
attended while in the service. This data was analysed to identify training needs of the providers. Most of
the providers had attended training programmes for vertical health programmes, for example, Child Survival
and Safe Motherhood (CSSM) training, All categories of providers expressed a need for a training to
familiarise themselves with the latest developments in their respective fields. 48 out of 70 providers would
like some training. Details are presented in Table 17 Annexure 1.
Box 2.4: Training needs expressed by health care providers included
in the facility study
Need for more training expressed by 10 doctors
•
Gynaecology (5)
•
•
Paediatrics (2)
•
•
STDs (2)
•
•
AIDS(1)
Latest developments (1)
Investigations(1) •
Computer (2)
Administrative (1)
Need for more training expressed by 7 ANMs
•
Women’s disease (3)
•
AIDS (1)
•
TB(1)
•
Gynaecology (2)
•
CSSM(1)
•
Report writing (1)
•
Family Planning (2)
•
Paediatrics (1)
•
Latest developments (1)
•
STD(1)
•
PID(1)
•
Communication skills (2)
Need for more training expressed by 10 CHVs
•
Women’s disease (6)
•
AIDS(1)
•
Investigations (1)
•
Latest developments (4)
•
STD(1)
•
Communication skills (1)
•
Family Planning (1)
•
TB(1)
Perceptions about referral system
Providers from all health care facilities reported referring clients to higher level of facilities. However, data
to substantiate this could not be obtained from the official records. Reasons for referral were non availability
of resources rather than for specialists’ opinion (68 and 2 out of 70 respectively).
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| Women Centred Health Project I Report of the End Evaluation
Quality of outreach services
Health post staff were asked to list indicators for assessing quality of outreach services. The indicators for
assessment of quality of care of outreach services identified by the providers do not reflect on providers'
responsibilities such as visits at regular intervals, IPC with women, health education to spouses and key
family members etc. that would result in improved quality of outreach services. Mention of improvement
in general health status and completion of target as indicators reflect lack of understanding about
complexities of factors determining health status and insensitivity towards clients’ perceptions of quality
of care.
Responses to this question when compared with the responses to earlier question on constituents of
quality of care’ shows disownership of responsibility for improvement of quality of care.
Table 2.8: Providers Perceptions of Indicators for assessment of quality of care
Indicators for assessment of quality of care (Providers Perception)
n=32
Increase in number of persons seeking health service
13
Improvement in general health status
7
Target achieved
5
Satisfaction expressed by clients (Asking people’)
5
Box 2.5: Key issues emerging from study of health care providers’
perceptions and attitudes towards women’s reproductive health
•
The fact that gynaecological conditions are reported among both the most common conditions
for which women sought treatment at the facilities and among conditions not reported by
women indicates the seriousness of the problem and need for RH services at community
level, (women usually hide RH conditions but still it is for these that they seek treatment
most probably when the problem becomes serious and affects daily routine. So for those
seeking treatment at health posts there will be many more who have not sought any help.)
.
Men and women have different attitudes towards social aspects of health problems of women. A
large proportion of health care providers did not relate gender issues as important factors influencing
women's health. Sensitisation of health care providers to factors influencing health and health
seeking behaviour — including gender, is essential for initiating RH services at health posts.
•
The responses to various questions aimed at eliciting perceptions and attitudes of health care
providers, indicate that a large proportion of health care providers are aware of the importance of
issues related to women’s health and quality of care. Suggestions for improvement in quality of
care are largely centred around meeting infrastructure needs—some of which, such as adequate
.
drugs supply, filling up of staff positions are prerequisites to effective health care delivery.
Low proportion of suggestions related to providers’ role in improving quality of care, points
towards disownership on part of the providers and a tendency to blame others for lacunae in
the services. The responses that put the onus of responsibility for improvement in quality of
care on clients, present cause for concern. It is clear from this study that there is a need for
sensitisation of health care providers to the concepts of quality of care from clients’ perspective.
23
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| Women Centred Health Project I Report of the End Evaluation
2.3. Exit interviews of users of municipal health services (1997)
Objectives - of this baseline study that was carried out in April - December 1997 were
•
To find out users’ awareness about the health services provided by various health care facilities
oftheMCGM
•
To document costs incurred by clients on availing the services
•
To explore whether clients were satisfied with the services and to elicit suggestions for improvement
in the services
Methodology
Study area and sample
Exit interviews of 402 clients who had availed of services from selected municipal health care facilities
from the project wards (H/E and G/N) were conducted.
Tool
A questionnaire was used to collect data on socio-economic information of the client, reason for seeking
treatment, accessibility in terms of time and money spent for availing services, users’ perception of
quality of services and suggestions for improving quality of care. (T-6.3 Annexure 6)
Data collection
Data was collected by female investigators. Six of them had social work qualifications (BSW and MSW)
and four were project ANMs. All investigators were trained for using of the tool. Quantitative data was
coded and analysed using SPSS.
Table 2.9: Sample profile for exit interviews
Respondent
Facilities
Total
Women
44
159
203
Number
Type_____________
Client
Children
Men
Dispensary
4
Health post
4
23
23
Post Partum Centre
2
42
42
Urban Health Centre
1
28
28
General Hospital
1
22
71
49
367
Parents of children
Health Post
4
29
29
immunised at
Dispensary
4
6
6
35
the facility
I
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| Women Centred Health Project I Report of the End Evaluation
Findings
Profile of respondents
82 percent of respondents were females. 78% of all respondents were in the 20-44 years age group. 69%
of women and 85% of men were literate. More than 60% came from households with single earner and an
average of 5 members. On average half of the respondents had walked upto ten minutes to reach the
health care facility. A comparatively larger proportion of clients had come to PPG and general hospital
from longer distances. 24% and 27% clients had spent more than 20 minutes to reach PPG and general
hospital respectively. (Table 18 Annexure 1)
Awareness about services
Awareness about even the key services provided through each of the facilities was low. For example
treatment of minor ailments which is a main function of dispensaries was reported by only 56% of the
respondents and immunisation at health post by 16 out of 23 respondents. More women than men
appeared to be more aware of the services provided through municipal health care facilities thus giving
basis to the myth that ‘municipal health care facilities are only for women and children’. (Table 19 Annexure 1)
Reasons for present visit
11 out of 23 respondents had Sought treatment for gynaecological conditions at health posts. Other
reasons were for symptoms related to gastro-intestinal tract and musculo-skeletal system. Dispensaries
were most used for conditions of musculo-skeletal system, respiratory system and gastro-intestinal
system. (Table 20 Annexure 1)
Average time spent at health care facility
Time spent at the health care facility increased from minimum for community level health post (21 minutes)
to peripheral hospitals (154 minutes - two and a half hours). 64 out of 71 had spent more than one hour
waiting at the peripheral hospital and 43 found it ‘too much’. (Table 21 Annexure 1)
Cost incurred on accessing the services
85% of respondents had walked to the health care facilities. Of the 56 who used autorickshaw / taxi/ bus/
train to reach the health care facilities, 40 had spent Rs. 5-19. (Table 22A and 22B Annexure 1)
Client-provider communication
Around 19% respondents reported being examined ‘in detaiP and said that they were explained the
diagnosis, were given a prescription for drugs and were asked to follow up. This proportion was lowest
(11.9) in PPG and 22.5% in secondary hospital. 78% respondents who answered the relevant questions,
reported satisfaction with privacy during consultation. 98% respondents reported understanding instructions
by doctors. 19% clarified their doubts by asking questions to doctors. 25 out of 283 respondents who did
not ask questions gave following reasons for not asking questions. (Table 23 Annexure 1)
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| Women Centred Health Project I Report of the End Evaluation
Box 2.6: Reasons for not asking questions / queries to doctors
•
Doctors do not talk to us (clients)
•
Doctors shout if asked questions
•
Doctors do not give proper answer
•
Very crowded clinic
•
Feel shy in presence of a male doctor
(findings from baseline study conducted in 1997, n=25)
Satisfaction with treatment received
81% of clients interviewed for the baseline study expressed satisfaction about doctors’ behaviour and
about the advice received. 93% of the 367 respondents were willing to visit the same health care facility in
future. In addition to ‘good services’; ‘free services’ and ‘close proximity of the health care facility to
residence’ appeared to be main reasons for willingness to use the same facility in future. (Table 24
Annexure 1)
25 respondents expressed dissatisfaction and said that they would not seek services at the health care
facilities in future. Though the number of clients saying this is small, reasons stated for this gave an idea
about clients’ perception of quality of care. Inconvenient timings and location of the facility, perceived poor
quality of care and disrespect shown by health care providers were the reasons mentioned by these
respondents. (Table 25 Annexure 1) •
Suggestions by respondents for improvement of quality of care centred around doctors.
Box 2.7: Suggestions for improvements in services
Examination should be done properly (57%)*
Examination should be done by doctors not by pharmacists or other staff (30%)*
Lady doctor should be available (3%)
Doctor should come on time (3%)
Increase staff (2%)
Doctor should always be available (1 %)
There should be better doctors (1 %)
Doctor should not leave in-between (1 %)
(* These were not explored in detail.)
(Footnote)
1 Stand alone : Some of the health posts are housed in the same premise as the dispensaries or hospitals whereas some are
situated in separate structures. Health posts situated In separate structures are referred to as ‘stand alone ’ health posts.
When health post and dispensary are located in the same premise, there is more coordination and cooperation between the
staff of the health post and the dispensary.
I
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I Women Centred Health Project I Report of the End Evaluation
Box 2.8: Key Issues emerging from exit interviews with users of municipal
health care services
•
Clients were not aware of all the services provided at health care facilities.
.
Health posts, post partum centres and urban health centre are mostly used for obstetric and
gynaecological conditions.
Clients could not freely ask questions to the doctors.
•
2.4. Observations of client-provider communication at gynaecology out-patient
clinic of a secondary hospital (1998)
In November 1998, client-provider communication in 11 gynaecology outpatient clinics at V N Desai
Hospital (a secondary hospital from H/E) were observed to document positive and negative episodes of
provider-client communication and context in which it occurs and to document factors other than
communication skills and attitudes that affect client-provider communication in gynaecology outpatient
clinic. During this period, two pairs of resident doctors, three nurses - one on any particular OPD day, one
attendant and one sweeper were observed. A diary of observations was maintained and later reviewed to
identify issues pertaining to client-provider communication.
Box 2.9: Key areas recorded in the diary
.
Context of communication — stresses experienced by health care providers and clients,
factors contributing to stressful situations and their effects on communication
•
•
Physical arrangement and its effect on communication
Interpersonal interactions between providers, between clients and clients and providers
The situation in the gynaecology outpatient clinic (OPD) was observed to identify / explore factors related
to (1) layout, (2) staff, and (3) workload of the OPD. Client-provider communication at different points in
the process of seeking consultation was observed. These were (a) while clients waited outside the OPD,
(b) while clients waited inside the OPD, (c) during consultation. Communication between providers was
also observed to explore effect of tensions between providers on providers’ communication with clients.
Salient observations are presented here.
Findings
Layout (as in 1999)
Gynaecology OPD is located on the first floor of the hospital building adjacent to the labour ward. In the
corridor outside the OPD, a bench provides seating arrangement for eight to ten patients at a time. The
OPD consists of two rooms connected by a passage. One of the rooms is used for examination of
patients.
27
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| Women Centred Health Project I Report of the End Evaluation
Examination room has a bench, where, around five patients can be seated at a time while waiting their
turn for examination. In this room there are two tables for the doctors and the nurse. The room itself is
divided into two by a L shaped cloth partition - doctors’ room, where patients wait before examination and
history is taken and a small cubicle with two gynaecological examination tables for PV examination. In
the doctors’ section of the room, there are two tables where two resident doctors, one or two interns and
a staff nurse sit. Adjoining this room, in the corridor there is a washroom for washing instruments and
gloves and a wash-basin for the doctors. A sterilliser is also kept here. At the other end of the corridor
there is a larger room with one table, two benches, one cupboard and one examination table. This room
is used by the honorary doctors when they come, or for attending to the patients who come for suture
removals, Cu-T insertion or removal etc.
There is only one door for entrance to and exit from the examination room. The door to the other room is
used only by health care providers.
Schematic diagram of the old layout is presented in Exhibit 3.
Exhibit 3: Schematic Diagram of Layout of the Out-patient Department
EXISTING
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PLAN OF GYNECOLOGY DEPARTMENT
28
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| Women Centred Health Project I Report of the End Evaluation
The staff
There are two units (sets of doctors) in the gynaecology department and on alternate days they take turns
at the OPD and the operation theatre. OPD is staffed by two resident doctors (one registrar, one
houseman), one or two interns, one staff nurse, one OPD assistant (ayabai), and one sweeper. The unit
in-charge — an honorary doctor, comes later in the day - at around 11.00 to 11.30 am. Besides these,
sometimes students (1 to 7) are also present. Interns take history of new cases and examine some of the
relatively simpler cases, but generally they work under guidance of the resident doctors.
Workload at the OPD
According to the hospital records, total attendance at the OPD on any given day in 1999 was around 50
to 70 patients. The OPD experiences a lull period (there are very few patients and they come at longer
intervals) of around 15 minutes after every one hour.
The unit that manages the OPD is also the one that handles emergencies. As a result, the doctors
sometimes are required to leave the OPD to conduct deliveries or surgeries or to monitor or examine
inpatients. This affects the functioning of the OPD. If one of the two resident doctors is not present, the
other doctor alone has to manage the OPD and the emergencies. This becomes stressful for the doctors
and the patients in the OPD have to bear the inconvenience and wait longer.
It is the attendant’s duty to let patients in, in small batches and to manage the patient flow. She also helps the
sweeper clean and prepare the gloves. She is expected to ’give position’ to the patient for the PV examination.
The sweeper is expected to clean-the OPD room before and after the out patient clinic hours. It is also her job
to clean the used gloves and instruments, clean the examination tables if soiled, and manage patient flow in
absence of the ayabai. Overall management of the OPD is the responsibility of the OPD staff nurse. She is
supposed to see that all the required instruments are available in the OPD, the gloves have been supplied,
variety of request forms (X-ray, ECG, USG, other investigations, admission papers, continuation sheets etc.)
are available to the doctors, to maintain various registers (mostly for ANC/PNC OPDs not for gynaecology
OPD), hand over reports of various examinations to the patients, to supervise the work of the OPD assistant
and the sweeper, to check whether the patients have the appropriate case-paper, to instruct the patients to get
ready for the PV examination, to ‘give position’ for the examination, if required -to assist the doctors in
examination and to be present when a male gynaecologist examines the patients.
1. Provider- Patient Interaction
Waiting outside the OPD
Generally the patients ahead in the queue tell those who come later to follow the queue. If this does not
happen, the patients crowd near the door and situation becomes chaotic. It is the attendant’s duty to ask
the patients to wait in the queue. Most of the time she is not at the door and if she was there, how well she
managed the patient flow, depended on how strict the doctors were. She was frequently observed to pick
up fights with relatives of the patients. She also was slightly more favourable to the BMC employees or
their relatives, who came for seeking treatment. Unless doctors refused to see them in-between, she
would let them in - ahead of those waiting in the queue. This was the most common reason for the fights
between the relatives and the attendant.
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[ Women Centred Health Project I Report of the End Evaluation
When attendant was not around, the sweeper managed the patient flow. She was found to be more
tolerant with the patients/relatives and managed to avoid the quarrels. She too, would bring along her
relatives or friends for consultations - but usually after 11 -11.30 am, when the patient load was quite low.
Waiting inside the OPD
One unit preferred that patients be sent in, in small batches, while the other unit preferred that only one
patient be sent in-side at a time. If more patients were let in, some times they all crowded around the
doctors’ tables. Usually the doctors repeatedly had to instruct them to sit on the bench and wait their
turn. Sometimes the sweeper or the attendant told them not to crowd around the tables, nurse did it very
rarely - and that too after being told by the doctor. But some old - regular patients were seen to explain
the rule of the OPD to the new-comers.
Consultation
If the interns or the students were present, they took the histories of the new patients. The patients would
then be asked to void urine and wait their turns for internal examinations. (The toilets are at the other end
of the corridor and attendants or the sweeper or the old patients instructed new patients about it.) If the
interns and students were not present, the resident doctors saw all the patients and took histories. In
such cases the waiting time for the patient was much more. Usually the doctors (residents and the
interns) told the patients to undress and lie on the bed. The nurse was rarely seen instructing or helping
the patients regarding this, even when the examining doctor was a male and in one of the units this lead
to clashes between the male resident doctor and the OPD staff nurse.
There were only two stools for the patients and if more than two doctors were present in the OPD, some
patients did not get to sit while explaining their complaints to the doctors. However, considering the
limited space available in the OPD, it seems impossible to accommodate more stools. When all the
doctors - two resident doctors and two interns — were present, even the staff nurse did not have a place to
sit and would have to sit in the inner room - but this (4 doctors being present at a time) was a rare situation.
Privacy
The OPD staff seemed to be sensitive to the need for privacy for the patients. Male relatives were not
allowed to enter the OPD unless asked by the examining doctors and the curtain at the door was always
drawn. The curtains around the examination tables were also drawn and the doctors and other staff would
all the time make sure to pull them closed after entering. In contrast to this, it was very surprising to see
that the patients were not sensitive enough. The relatives - males and females - kept peeping through the
door and while doing this opened the curtains. This often lead to arguments between the ayabai and the
relatives and the doctors and the relatives. The patients themselves were not much different. They kept
peeping inside (the curtains around the examination tables) till the doctors ordered them out of the room.
These patients who did not care about the privacy of those being examined, were very particular when it
was their turn. They were seen telling the ayabai to pull the curtains closed.
Doctor-Patient Communication
Generally, doctors spoke softly with the patients and their consultations could not be heard from the
place where other patients sat. All the four doctors were patient with the patients, listened to all of their
complaints without interrupting them, did not get angry with them, did not shout, explained whatever that
needed to be explained, and counseled whenever required. But occasionally they lost their tempers,
especially when the workload was high (OPD was very crowded, or if single doctor had been managing
the OPD, or if frequently they had to attend to labour ward), or if a patient could not understand repeated
- more than 2-3 times—instructions, or did not follow the advice.
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j Women Centred Health Project I Report of the End Evaluation
Doctor- Nurse Communication
In the OPD setting the staff nurse has an important role to play, especially in the gynaecological OPD.
For the first half of the period of observation, the regular OPD staff nurse for the gynaecology OPD was on
leave. During her absence, two reliever nurses managed the OPD . One of them had been working as a
nurse since three years and had come to this particular hospital only since past six months. She had not
worked much in the gynaecology department. She did not know anything about the registers, reports,
forms, and in general what the doctors expected from her. On one particular day only one male resident
doctor was managing the OPD. He repeatedly had to tell her to instruct the patient about undressing, to
‘give position’ for internal examination, and to wait with him when he examined the patient. He did it for
around first 10 patients, but later on was irritated and stopped telling her anything. But this nurse was
helpful to the patients and tried to explain whatever she could. She also was quite sympathetic towards
the patients - if someone was in discomfort, she brought it to the doctor’s notice, reassured patients,
explained treatment etc. (May be because she was pregnant and could identify with the patients).
The regular OPD nurse’s behaviour towards both the units differed markedly. Both units had one male
doctor each. The nurse would assist one of them and even after repeatedly being told by the other, would
not assist him, even when he was the only doctor in the OPD and examining patients. On one day, after
he wore gloves, this doctor realised that the instrument he wanted was not in the tray and asked the nurse
to bring it from the steriliser. She ignored him totally. Later he took the instrument from the steriliser. On
another occasion when the doctor insisted that she be present when he examined the patients, she
yelled at the patients or said something rude to them. He did not approve of this and he was heard telling
her not to say such things. (Eventually he stopped telling her to accompany him during examination.)
Nurse -Patient
The other reliever nurse was an old-timer. She was noisy, harsh, rude and insensitive in her behaviour.
Irrespective of the reason for which these patients came to the OPD, she was seen advising them about
getting TL done. She also looked down upon the patients. According to her ‘these patients are illiterate,
they do not have any sense and they just want more children’ (so at every possible opportunity they
should be told about TL, more children was the only problem, telling them about TL was the best advice
they could have received - this is the impression I got from whatever she was saying—to the patients,
other fellow nurses and to me).
Despite her long experience with the gynaecological patients, sometimes, the gynaecology OPD nurse
was extremely insensitive to patients. When the patient load was high and the OPD went on for a longer
time, she tried to send away as many patients as she could. She also tended to assume that all these
patients came there for ANC registration (ANC OPD starts in the same place after gynaecology OPD is
over). In her zeal, once she told a young woman to come in the afternoon. The woman was confused and
asked why. The nurse got angry with her and said ‘aren’t you pregnant? Don’t you understand after so
many months that you have to come in the afternoon?’ In fact this woman had come for treatment of
primary infertility and was greatly hurt by the nurse’s remark. This brought tears to her eyes. What was
worse was that the nurse did not even apologise to the woman.
This same nurse was at times very nice to the patients and went out of the way to help them, for example
by fetching their X-ray reports from the radiology department, taking the ECG to the medicine department
for reporting (usually these things take time and the patient is asked to come on the next day), reaching
the patient in labour to the ward. For a patient in labour accompanied by a old female relative, this nurse
herself had got the admission papers prepared.
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| Women Centred Health Project I Report of the End Evaluation
Attendant-Patient
The patients interact with ayabai and sweeper while they are waiting their turn for examination. Usually
they are the ones who instruct the patients about undressing and ‘give position’ for PV examination. The
sweeper was more tolerant with the patients than the ayabai.
J
it
r
Doctor-Doctor
Both the units had two resident doctors each - one registrar and one houseman. In one unit the residents had
very good rapport with each other and shared the work equally. In the other unit the registrar was academically
junior to the houseman and this seemed to affect their functioning. This houseman rarely came to the OPD and
when he did, came only for a short time. As a result, the other doctor had to single handedly manage the OPD.
This stressed her out and affected her behaviour with the patients. Both the doctors in this unit were frustrated
and this sometimes, seemed to reflect in their interaction with patients in the OPD.
One day resident doctors who had excellent rapport with each other had an argument about a case and the
registrar shouted at the houseman in the OPD - in front of patients and the other staff. Although the reason
was genuine, the houseman felt extremely insulted and left the OPD. Later on she said that this (shouting
at her in public) was the only negative point about the registrar, who otherwise she thought was a good
doctor and friend.
The honorary doctors came in late and examined only complicated cases. Usually they spent less than
half an hour in the OPD.
I
h •
r
t
t
£
Communication between the OPD doctors and the administrative staff
In a secondary hospital the Assistant Medical Officers (AMO) are supposed to help the resident doctors
in solving day to day problems — to help when there are less number of doctors, see to it that the
instruments are repaired on time, all the equipment are available and in working conditions. On more than
one occasion it was observed that in a heavy OPD there was only one resident doctor (neither interns nor
students were present) and had requested the AMOs to come and help for sometime. During the period
of observation, the AMOs were never seen to help in the gynaecology OPD. On a particular day, the
doctor was told that there was a shortage of doctors and if other OPDs finished early then some one
would come and help in the gynaecology OPD. That day the gynaecology OPD went on till 2.00 p.m. but
the AMO did not even visit the OPD or ask if still help was needed. The residents however were expected
to help out other departments after finishing their own work.
A senior administrative officer was seen talking rudely with the resident doctors (shouting at them) in front
of patients and the other staff.
These incidents although, minor, created ill-feelings in the minds of the residents about the administrative staff.
Patient - Patient interaction
In municipal hospital, at all stages patients are seen helping other patients. In gynaecology OPD, routinely,
new patients were informed and helped regarding the procedures in the OPD (wait till the doctor calls you,
r
go to the interns or students — chhote doctor, void urine before the doctor examines you, location of the
toilet, places where it was possible to get ultra-sonography done at cheaper cost, locations of various
investigation departments etc.) by the old patients. Patients also looked after each other’s children while
the other underwent examination. The patients also discussed each other’s health problems. One other
issue they discussed at length was that of contraception use. Patients talked about their experiences
regarding repeated pregnancies, MTPs, copper T and it’s complications, advantages of TL over copper T,
oral pills and it’s disadvantages etc.
*1.
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2. Reaction towards a male gynaecologist
Both the units observed, had one male resident doctor each. But patients did not seem to have any
problems with that. Of the 11 days when OPD was observed, only on one particular day, the patients
were seen to refuse examination by the male doctor or show some extent of hesitation.
One middle aged woman had come for check-up. She seemed slightly uncomfortable but managed to
give detailed history about her complaint. This was taken down by a female student. In this unit the
doctors took turns at conducting pv examination. When it was this woman’s turn for examination, the
male doctor was conducting the examination. She felt shy and refused to go in. She even tried leaving the
OPD but the woman accompanying her — slightly younger in age and better educated — prevented her
from doing so. “Would the doctor ask you to do anything wrong or unnecessary? There is something
wrong with your uterus (garbh pishvi). How would he know without examining from inside ? , she said.
This seemed to convince the patient about the need for pv examination but she was still hesitant about
letting a male doctor do it. The accompanying relative then said. “He is of same age as your son. You
shouldn’t feel shy of him. Anyway the examination has to be done so please hurry up”. The patient then
went in for the examination. When she went in, the doctor asked her if she had made up her mind about
having a pv examination done. Only when she said ‘yes’, he told her to lie on the table.
On the same day an adolescent.girl had come to the OPD. She too was reluctant to let the male doctor
examine her. The doctor explained to her what the examination was about, what he would learn from the
examination and why it was necessary. He also assured her that it would not hurt her and sensing that
she was feeling shy he asked one patient he had examined to tell the girl how it felt during the examination.
That patient told the girl that it doesn’t hurt, doesn’t take much time and whether the doctor is male or
female doesn’t make much difference. The doctor then gave the girl some time to think and then asked
her if she was willing for examination. The nurse and the sweeper also told her that since she had waited so
long in the OPD she should undergo examination. The doctor had spent almost 15 minutes explaining to her.
Box 2.10: Key issues identified through observation of client-provider
communication at gynaecology outpatient clinic at a secondary hospital
•
The layout of the OPD with only one door for entry and exit lent itself for crowding and chaos
during peak hours of the OPD. Inadequate and inappropriate seating arrangement for doctors
resulted in patients standing while doctors recorded history or treatment after examination.
Non-availability of a table for OPD nurse contributed to her not being in the OPD when
•
•
•
•
doctors / patients needed her assistance.
Overcrowding of patients at the doctors’ table pressurised doctors and usually ended in
doctors being rude with patients.
Quality of client - provider depended on their attitudes and personal traits as well as
environment in the OPD. Communication among the health care providers influenced the
quality of providers’ communication with clients.
The health care providers from the outpatient clinic lacked a forum for discussion of problems
related to their work situation and frustrations were at times taken out on patients.
Interventions to improve client-provider communication will have to consider factors other
than attitudes and communication skills of health care providers.
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2.5. Identifying counselling needs of women seeking consultation at gynaecology
outpatient clinic at a secondary hospital (1999)
In November 1999, 50 episodes of client-provider communication were observed to identify unmet information
and counselling needs of clients seeking services at gynaecology OPD. Another objective of the study
was to explore feasibility of improving client-provider communication in the OPDs of public hospitals. The
observations documented through this study were used to develop case-studies that were used in training
workshops on Communication and Counseling skills.
r
Instances where the providers did not meet clients’ information and counselling needs were documented.
The observations helped in identifying some situations where possibility of clients’ information and counselling
needs being neglected or denied was more than others. Frequently observed cases in the OPD in need of
counselling and information were when women asked for MTP without consenting to Cu-T or TL., men
r
./
were denied participation in consultation process, women were not given adequate information about
available contraceptives to enable them to make an informed choice.
Findings
Counselling needs of clients
•
Women especially those presenting with infertility / childlessness needed emotional support. There
also was need to discuss sexual problems with couples presenting with infertility. Privacy essential
for such discussions was not ensured in the OPD and this prevented women/couples from sharing
critical sensitive information related to the condition thus causing delay in treatment.
•
When women with small children ask for MTP, doctors insist on Cu-T. If women do not agree to Cu-T
this leads to arguments between doctors and patients. It was observed that many women had inadequate
knowledge about contraceptives and /or family problems that influenced their decisions about
contraceptives. OPD situation prevented health care providers from exploring anxieties that these
women faced and addressing them. The women instead were labeled as ‘morons’ and ‘being ignorant’.
•
Couples that seemed to be seeking MTP after sex determination need counselling. Sometimes
husband or family members force the woman for an abortion. It is important to talk to decision
makers in the family and to discourage them from terminating the pregnancy.
•
Adolescent girls who seek treatment for menstrual problems or white discharge find the OPD
atmosphere inhibiting and scary. They usually find it difficult to talk to doctors and this leads to rude
behaviour from doctors and girls go without consultation.
•
Women are not provided information about what to expect during the internal examination (per vagina
examination) and many do not easily follow doctors’ instructions. This results in these women being
shouted at and insulted by the health care providers.
•
Language barrier affects history taking when doctors do not understand what women are trying to say
and vice-versa.
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| Women Centred Health Project I Report of the End Evaluation
Box 2.11: Situations that irritated the doctors and resulted in their being
rude with clients
In gynaecology OPD
•
patients came too close to doctors and talked to them
•
patients crowded around the doctors’ table
•
patients could not effectively/ clearly express their problem
•
patients could not give obstetric history — number of pregnancies, dates for last menstrual
period, date of when she had a spontaneous abortion
•
patients, especially lactating mothers came for MTP
•
husbands came in and requested wives’MTP
•
patients did not understand instructions and asked repeatedly
InANC OPD
•
women did not have blood report or sonography findings recorded on case papers
•
case papers in records file were not in chronological order or not properly maintained
•
women asked the date for follow up after being told once
women needed urgent investigations or medicines and did not have money on them
women with case papers for another unit came to this OPD
Factors affecting client-provider communication
Interpersonal communication between providers
When one resident doctor attends to more clients than the other, it results in him/her spending lesser
time per patient and that affects communication. Also being burdened with work, promotes frustration in
the doctor which then is taken out on clients. Tensions between doctors in the OPD can cause
inconvenience to clients when one of the two refuses to see clients waiting in queue to see him/her. This
increases waiting time of the client and the doctor who is forced to attend to the client is more likely to be
dismissive of her.
It was also observed that nurses and attendants did not perform their roles as members of the OPD team.
They did not assist doctors and did not carry out doctors’ instructions to their satisfaction. When the
nurse or attendant did not accompany male doctor for internal examination it resulted in tension between
the doctor and the staff.
L
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| Women Centred Health Project I Report of the End Evaluation
Organisation of physical facilities
Most patients are required to void urine before internal examination. Toilets and wash basins for clients /
patients are located outside the OPD. This increases waiting time for patients and affects patient flow.
Women who come for Cu-T insertion are asked to collect the Cu-T from the health post located on the
ground floor of the hospital building and queue up again in the gynaecology OPD for insertion.
Inadequate seating arrangements mean that patients have to stand while the doctors record their history.
Physical set up of the OPD does not allow smooth patient flow. This increases patients’ waiting time on
the examination table. Average waiting time on examination table ranged from 10 to 15 minutes.
Insensitivity and attitudinal problems
It was observed that the resident doctors take interest in a patient and make efforts to explain things to
patient only when the ‘case’ is interesting for them and contributes to newer learnings.
Patients who are relatives of the hospital staff are treated with more respect and consideration. Poor
patients are not perceived as having any self respect or intelligence and are made to feel obligated for
receiving free treatment.
Box 2.12: Key issues identified through study for exploring counselling needs
of women seeking services at gynaecology OPD
•
Quality of communication varies from person to person and at different times for the same
person depending on other contextual factors such as work load, communication between
doctors, among staff and so on.
•
Socio-cultural gap between the providers and patients appears to be a barrier in communication.
•
Language, terminology and mannerisms used by the doctors are not understood by patients
and vice-versa, adversely affecting the quality of care in terms of misdiagnosis, non-compliance
and informed decision making.
•
Lack of privacy and heavy load of patients makes it difficult for the doctors to spend enough
time with the women requiring counselling. Women seeking services for contraception are
worst affected by this.
2.6. Review of staff and instruments at health posts and dispensaries (2000)
Inability of FTMOs and MO i/c dispensary to initiate gynaecology outpatient clinics at health posts and
dispensaries after the clinicians’ training prompted the project to review physical resources crucial to
provision of gynaecological services. A review of health posts and dispensaries from H/E and G/N was
conducted in April - May 2000. It was observed that each one of the health posts and dispensaries had
36
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| Women Centred Health Project I Report of the End Evaluation
problems either with inadequate or non-functional equipment and or vacant staff positions that affected
quality of services provided by these facilities. Health posts and dispensaries in H/E ward faced more
severe problem regarding availability of drugs required for treatment of gynaecological conditions than
those in G/N. (Table 8A and 8B Annexure 1)
The findings of the survey were discussed with health care providers from project wards. Key suggestions
by the providers were
.
Imprest amount (petty cash assigned for each health post for minor repairs etc.) should be increased
to Rs. 500 /-.
•
Relieving substitutes should be sanctioned for all cadres of staff to ensure best utilisation of time of all
staff
.
At the level of Medical Officers of Health, minor repairs of equipment amounting upto Rs. 1000/- for
repairs of steriliser and BP apparatus etc. should be allowed. Medical officers of health should get it
done through private contractors as repairs of these through MCGM is a time consuming procedure.
Table 2.10: Profile of health posts and dispensaries from H/E and G/N:
Findings of the survey, May 2000
Health post / Dispensary Problem I Issue identified
G/N _________________
Gulbai Health Post/Gulbai Inadequate and irregular water
Dispensary____________
Vacant post -1 MPW
Gulbai Health Post
Cusco’s Speculum not available
T. Flagyl not available
Gulbai
Dispensary Vacant post -1 Sweeper
(Upgraded Dispensary)
Gokhale Road Health Post Sterilisers not working (pressure
/ Dispensary__________ _ cookers used for sterilisation)
Gokhale Road Dispensary. Inadequate privacy_________
Gokhale Road H.P.(Non Vacant post -1 ANM
Slum)
____________
Transit Camp Dispensary. Water problem
Shahu Nagar Dispensary. Inadequate privacy
Oven in laboratory
Vacant post -1 ANM
T. Flagyl not available
Welkarwadi Health Post / Vacant posts - 2 ANMs, 1 MPW,
Dispensary____________ 1 Labour_________________
Antiseptic not available______
Welkarwadi Dispensary
Shastri Nagar H.P.(Slum) Vacant post -1 MPW________
Autoclave leakingSteriliser not
working__________________
U.H.C. Health Post (Slum) Vacant post -1 MPW I_______
Kumbharwada
Health Vacant posts -1 ANM, 2 MPW
Male FTMO
Post(Slum)
Pilla Bangla Health Post
I
37
Proposed solution
A separate pipeline or a more powerful water
pump___________ ______ _______________
Position need to be filled
Need supply
Can be shared with dispensary
Staff needs to be appointed
Procedure for repairing equipment at ward level
through private parties needs to be sanctioned.
Curtains will serve purpose. MOH to take action
Positions need to be fulfilled
Needs to be looked at by MOH and reported
back_____________ ___ ______________ _—
Reorganization of space required. MOH with help of
AHO and DEHO may make the necessary changes.
Procedure for repairing equipment at ward level
through private parties needs to be sanctioned
Positions need to be fulfilled.
Can be shared with dispensary
__
Positions need to be fulfilled
Can be shared with health post
Positions need to be fulfilled_______________
Procedure for repairing equipment at ward level
through private parties needs to be sanctioned
Positions need to be fulfilled_______________
Positions need to be fulfilled Female FTMO could
be posted at health post
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| Women Centred Health Project I Report of the End Evaluation
Health post / Dispensary
Problem / Issue identified
Proposed solution___________________
Steriliser, autoclave,morison Procedure for repairing equipment at ward level
lamp - nonfunctional________ through private parties needs to be sanctioned
Kumbharwada Dispensary Antibiotics not available___________________________
Sr.M.O. and M.O.H. to investigate____________
Kumbharwada Health Post Vaginal pessaries not available MOH and AHO(Bureau) to look into this.
Mahim Mat. Home Health Vacant posts - 3 ANM, 2 MPW I Positions need to be fulfilled
Post M.P. (mix)__________
Labour Camp
Autoclave leakingSteriliser not Procedure for repairing equipment at ward level
working •______________
through private parties needs to be sanctioned
SHED
Steriliser not working
Procedure for repairing equipment at ward level
______________________ through private parties needs to be sanctioned
Note: Some equipment need scrapping. But unless it is scrapped, new equipment cannot be purchased. Having about
30% stand by equipment in the ward office could help in better functioning of the facilities. Need to take D.M.C.’s sanction
for this.________________
H/E___________________
S.V.Nagar Dispensary / Male M.O.I/c
Combination of male female doctors in one
Health Post
Male FTMO
premises_______________________________
B.P.Apparatus and Steriliser in Procedure for repairing equipment at ward level
non-working condition_______ through private parties needs to be sanctioned
Non availability of Gynaecological Needs supply
medicines and Vaginal Pessaries
S.V.Nagar Dispensary
Lack of privacy______
Curtain will serve the purpose_______
Golibar Health Post
Written permission from DEHO/AHO(Bureau) need to follow up
MHADA needed______
Jawahar Nagr Dispensary Inadequate and irregular water Review by MOH and/or appropriate authorities
supply____________________
Vaginal Pessaries not available Needs supply___________________________
Kalina H.P.
Vacant post -1 ANM_________ FTMO needs to be appointed_______________
Steriliser not working
Procedure for repairing equipment at ward level
through private parties needs to be sanctioned
Bharat Nagar Health Post / Male M.O.I/c
Combination of male female doctors in one
Dispensary____________ Male FTMO________________ premises_______________________________
Bharat Nagar Health Post Vacant posts - 3 ANMs_______ Positions need to be filled_________________
Gynaecological medicines and Needs supply
Vaginal Pessaries not available
Steriliser not working
Procedure for repairing equipment at ward level
through private parties needs to be sanctioned
Kherwadi Health Post
Vacant post -1 ANM
FTMO needs to be appointedPosition needs to
be filled.________________________________
Govt. Colony Health Post
Vacant posts - 2 ANMs
Positions need to be filled_________________
V.N.Desai Health Post
FTMO needs to be appointed_______________
Vakola Health Post
Vacant posts-1 ANM, 1 MPW
Positions need to be filled_________________
Vaginal Pessaries not available Needs supply___________________________
Prabhat Colony Dispensary Vaginal Pessaries not available Needs supply
Box 2.13: Key issues identified through review of staff and instruments at
health posts and dispensaries
•
Strengthening of health posts and dispensaries in terms of physical resources is essential
for initiation of gynaecology clinics.
•
Vacant positions need to be filled.
•
Administrative procedures for repairs and procurement need to be reviewed and feasible
alternatives explored.
More active involvement of senior administrators (AHO/ DEHO) will provide guidance in
addressing factors hindering interventions for improving quality of care.
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| Women Centred Health Project I Report of the End Evaluation
2.7.
Exit interviews at gynaecology out-patient clinics at health posts (2001)
Women Centred Health Project started its activities for increasing the range of reproductive health services
with a vision of initiating gynaecology services through all health posts and dispensaries from the two
project wards. It was expected that these services would be provided not as a separate project activity
but as a part of the routine duties of these facilities. The project set a goal of initiating one gynaecology
clinic every month. However, obstacles in the form of lack of motivation and non-availability of basic
minimum resources hindered the progress. Between April and August 2001 gynaecology outpatient clinics
were initiated in three health posts by the project. In December 2001 a small study was conducted to
assess the effectiveness of gynaecology clinics initiated by WCHP and to explore need for and feasibility
of initiating gynaecology outpatient clinics at health posts and dispensaries.
Objectives of the study were to explore
•
•
need for such services at community level
awareness about availability of gynaecological services among women from surrounding community
•
ways of extending the reach of such services to a wider group of women
Three health posts where gynaecology clinics were initiated by WCHP (Welkarwadi, S V Nagar, Shastri
Nagar) and a health post in G/N ward where WCHP had not initiated a gynaecology clinic (Pila Bungalow)
were included in the study. Clients availing services at the select health posts on days of gynaecology
outpatient clinics were included in the study. Data from Pila Bungalow health post, which does not have
a gynaecology clinic initiated by WCHP, was collected during the Family Health Awareness Campaign
— a 15 days programme conducted by Mumbai District AIDS Control Society for diagnosis and treatment
of reproductive tract infections including sexually transmitted infections. Clients were explained the purpose
of the study and verbal consent was sought before conducting the interviews. A semi-structured
questionnaire (T-6.4 Annexure 6) was used for data collection and quantitative data was manually analysed.
Table 2.11 — Exit interviews of users of gynaecology clinics — Profile of health posts
Shastri Nagar
S V Nagar
Welkar Wadi
Date of initiation of gynaecology clinic
April 9, 2001
July 27, 2001
August 16, 2001
Duration till survey_______________________
8 months
5 months
4 months
Average utilisation for three months prior to survey
9
8
Not available
Box 2.14: Topics covered in the questionnaire
Socio-economic information
Condition for which help is sought
Whether health post is the first contact with health care delivery system
Reason for seeking services at the health post
Client-provider communication
Whether pv examination was carried out
Client’s perspective of privacy
Awareness about services available at the health post
Suggestions for improvement in quality of services provided at the health post
Comparison with experiences of treatment at a private clinic
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I Women Centred Health Project
I Report of the End Evaluation
Findings
Socio-economic profile of the respondents
37 out of 45 women interviewed during the study were married and 27 of 45 were between 18 to 30 years
of age. Proportion of adolescent girls and 40+ women was low. 10 respondents could not read or write and
1
27 had completed 5 to 10 years of education. Four of the 45 respondents were gainfully employed. Since
most of the respondents were non-earners, information about educational and occupational status of their
spouses and estimated monthly family income was gathered. Husbands of six respondents were employed
in the public sector, 11 were self employed and 12 worked as semi-skilled or unskilled workers in the
unorganised.sector. Majority (38) of these women came from families with four or more members. 17
women reported to be from households with monthly income of less than Rs. 2000. (Table 26 Annexure 1)
Reason for seeking treatment at gynaecology clinic
r
Excessive white discharge (19 out of 45 )and dysmenorrhoea (11) were the main reasons for seeking
treatment. For 15 respondents gynaecology clinic was the first place of contact with health care system.
None of these 15 reported any prior treatment including home remedies. Before coming to the health
posts 11 respondents had sought treatment from private practitioners and three from hospital. One respondent
reported home remedies for burning micturation. (Table 27 Annexure 1)
Box 2.15: Reason for seeking treatment at the gynaecology out-patient clinic
at health post
White discharge
ForCu-T insertion
Itching, boils on external genitalia
To check Cu-T
Pain during menstruation
•
For Cu-T removal
Irregular periods
•
Pain during intercourse
Menorrhagia
•
Prolapse uterus
Infertility
Other
•
Aches and pains (back, arms, legs)
Source of information about gynaecology clinic/services at health posts
23 respondents including two from Pila Bungalow health post had been told about the availability of
gynaecological services at health posts by community health volunteers or other outreach workers.
Awareness about services available at health posts
Respondents were asked to list services they thought were available at health posts. 16 of the 45
respondents could list some services provided by health posts. 13 knew about copper-T insertion, two
each reported ANC and gynaecological check up. But only three reported immunisation which is one of
the major activities of the health posts.
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| Women Centred Health Project I Report of the End Evaluation
Table 2.13: Awareness of services available at health posts
Awareness of services available at health posts
Shastri Nagar
S V Nagar
9
1
3
1
1
Cu-T insertion
Triple Polio immunisation
Gynaecological services
Antenatal Care
Treatment of cough, cold
TB investigation
Give medicines____________
‘Data not available for Pila Bungalow Health post
Welkar Wadi Total
1
1
1
1
1
1
1
1
1
13
3
2
2
1
1
2
Quality of care
Gynaecological (PV) examination
17 of the 45 respondents from all four health posts reported having had internal examination and all of
these reported satisfaction about privacy during examination.
Clien t-pro vider communication
Respondents were asked if they were told what was wrong with them /informed about diagnosis and
treatment. Communication was broadly grouped as (1) reassurance by the doctor, (2) technical/ clinical
information, (3) technical advice, (4) hygiene related advice, (5) advice related to sexual relations, (6)
other. 15 women were explained about their condition. 28 were advised for further treatment.
Table 2.14: Contents of communication with doctor
Nature of communication
Technical advice
Clinical information
Reassurance
Advice regarding hygiene
Advice about sexual relations
Shastri Nagar| S V Nagar
3
1
1
1
10
7
2
10
5
1
1
Welkar Wadi
1
25 of 45 respondents believed that this information will benefit them.
41
1
Pila Bungalow
5
2
1
Total
28
15
4
2
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| Women Centred Health Project I Report of the End Evaluation
Box 2.16: Examples of information/ advice given by doctors
(1) reassurance by the doctor
“It will be alright. Take the medicines. Come back if you have any problems.”
(2) clinical information
“Diabetes has increased. You need to take__ injections”.
“Breathlessness is because of BP medicines”
(3) technical advice,
“You will have to go to Sion Hospital (tertiary hospital). We need to find out whether the gaanth
(tumor/swelling) has fluids inside or whether it is solid from inside. ”
(4) hygiene related advice
“Wear cotton underclothes, use soft cloth during menstruation. Change the cloth two to three
times a day. Wash the cloth clean.
(5) advice related to sexual relations,
“It is alright to continue sexual relations. ”
(6) other
“If you do not feel better after taking medicines, follow up at Sion Hospital.”
Opinion about services received
40 respondents shared their opinion about the services provided by gynaecology clinics at health posts.
Two of them had negative experiences —"... they do not listen to us. ”, “CHVs were yelling. ” 24 of the rest
found the services to be ‘OK’. Eight respondents specifically appreciated communication style of doctors
Table 2.15: Feedback on services received
Opinions about services received
Health Posts
Shastri Nagar S V Nagar
OK
Doctor explained properly
Examined properly
Close to residence
Get medicines
Effective treatment (cures the ailment)
Free treatment
Gynaecological services available
Did not listen to client
CHV shouted
8
9
4
2
1
1
2
1
1
Total
Welkar Wadi Pila
2
3
1
1
1
1
1
Bungalow n = 40
5
24
8
3
2
2
1
1
1
1
1
Need for improvement
25 of the 45 respondents did not feel any need for improvement in the services provided by heath posts.
Suggestions by the respondents included physical rearrangement for comfortable ambience, waiting time
and inconvenient timings.
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Table 2.16: Suggestions for improvement of services
No need for improvement
Total
Health Posts
Suggestion
Shastri Nagar S V Nagar Welkar Wadi Pila Bungalow
6
4
11
5
2
Should get medicines
25
2
Clinic should be open in morning
and evening
1
1
1
2
Should not be made to wait in
queue, prompt service
1
Clutter should be removed
1
1
Seating arrangement
1
1
CHVs should behave properly
1
1
Clinic should be bigger
1
1
1
1
Treatment for all conditions
should be provided
Difference between private and public sector
Seven respondents did not have any prior experiences about private sector and six did not find any
difference between the two. Of those who responded to this question, 22 pointed out that services through
health posts are free of cost. Four have commented on treatment given through municipal facilities
"treatment from private is not effective therefore we come to municipal facilities’^), "private doctors
change medicines frequently, in municipal facilities they call after the course is complete’’^), "in municipal
facilities detailed history is asked before prescribing treatment" (1).
Box 2.17: Key issues identified through exit interviews at gynaecology clinics
at health posts
•
Gynaecology clinics at health posts are utilised primarily by married women between 18-30
years of age from poorer section of society.
•
Unlike the common belief, very few (1 out of 45) women from areas surrounding health posts
try home remedies. For a large proportion of the sample, visit to health post was the first
contact with health care system.
•
Women appear to be aware that gynaecology clinics are conducted at health posts but more
information on specific services provided by health posts might result in increased utilisation.
•
Free treatment or lower costs as compared to private sector health facilities is perceived to
be a plus point of municipal services.
•
Behaviour of health care providers, seating arrangement and streamlining crowds need
improvement.
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2.8 Baseline study for counselling centre at gynaecology outpatient clinic of a
secondary hospital (2001)
Findings of the baseline studies to identify factors affecting client-provider communication and counselling
needs of clients were discussed with staff at the OPD. It was suggested by the medical as well as
paramedical staff that an information and counselling centre at the OPD would help to a great extent in
reducing the stress experienced by clients as well as providers and thus in improving the quality of
communication. Based on this, the project planned to start an information and counselling centre at the
OPD. A baseline survey was conducted at the VND (test) and MWD (control) hospitals to document the
experiences of clients seeking services at the gynaecology OPD which in turn would be useful in assessing
the effect of the proposed intervention.
Box 2.18: Effect of factors affecting client provider communication on quality
of care: Conceptual Framework
Problem statement: Poor communication between providers and patients/clients is an important
factor affecting quality of care provided at the gynaecology OPD of secondary hospital and
contributes to patient/client as well as provider dissatisfaction.
Factors affecting provider-client communication
1. Physical structure
2. Logistics
•
•
•
•
•
•
•
•
•
Lay out of the OPD
Waiting area - inadequate space
Patient flow
Sitting arrangement of doctors
Lay out of the examination room
Degree of privacy
Location of toilets
Availability of drinking water in the OPD
Benches for patients in the waiting area and in
the examination room
Stools for patients to sit in the examination room
Benches for accompanying persons in waiting area
Supply of gloves
Supply of instruments
Availability of curtains, drawsheets and rags.
Screen for honorary room
•
•
•
•
•
•
3. Human resource (organisational)
•
Clarity of roles of paramedical staff, i.e. nurse, attendant, sweeper
•
•
Conflict between the team members
Availability of nurse to prepare the patient for internal examination and explaining treatment,
diagnosis, precautions, investigations, etc.
•
Attitude of doctors, nurses towards patients
•
Educational status of patients, confidence of patients in negotiating situations at hospital
situation, patients’ ability to ask queries and clarify doubts
•
Doctor-Patient ratio (Number of patients per doctor per clinic)
Hypothesis
Inappropriate layout of the OPD, ineffective patient flow management, lack of clarity of roles of the
paramedical staff in the OPD, attitudes of the providers towards the patients and poor / inadequate
supply of logistics contribute to poor provider-client communication and patient and provider
dissatisfaction.
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i Women Centred Health Project I Report of the End Evaluation
Objectives of the study were to
•
assess the effect of patient flow / on provider-client communication
•
identify extent of need for intensive counseling and information
•
assess effect of behaviour modification on communication style of the providers
•
assess impact of providing information on what to expect in the OPD etc. on provider client
communication
•
assess the feasibility of replication of such exercise for all BMC facilities.
•
institutionalise the interventions showing positive effect on provider-client communication.
Methodology
A secondary hospital with eight basic specialities (VND Hospital) located in one of the project wards was
identified as a site for intervention. In view of the ongoing Reproductive and Child Health Training to all
cadres at health care providers that included sessions on communication and counselling, it was felt
necessary to include a control hospital (MWD Hospital) in the study. The control hospital was selected
on the basis of bed strength, location, utilisation of gynaecology OPD and type of population availing of
hospital services. Detailed profile of hospitals is presented in Table 28 Annexure 1. Staff and administrators,
at both the hospitals were informed of the objectives of the study and that ‘experiences of clients availing
of out patient services through gynaecology department were being recorded’.
Study Sample
293 and 322 women seeking treatment from the gynaecology OPDs of VNDH and MWDH respectively
were interviewed for the survey. At VNDH every fifth client was included in the sample. At MWDH every
client was included in the sample. Data collection was completed over a period of six months (August
2001 - January 2002). Clients were informed about the objective of the study and were given a choice to
participate. A pre-coded questionnaire / interview schedule was used to interview the clients. Clients
included in the sample were interviewed after they completed the consultation but before they underwent
the investigations. The interview schedule is included in Annexure 6 (T-6.5 Annexure 6).
A rigorous process was followed to ensure validity of the interview schedule. In the initial phase, client
provider communication for clients recruited into the study was observed and recorded using a pre-tested
observation checklist. Results of the validation process are presented elsewhere, (unpublished).
Validation exercise
A study was launched to explore possibility of using exit interviews instead of observations using checklists
for evaluating client- provider communication for the purpose of assessing the impact of the intervention.
Results showed that most of the information gathered through the use of observation checklist could be
obtained through exit interviews. However, data regarding situations requiring interpretation on behalf of
the observer or the respondent showed variation. The process and main findings of this exercise are
discussed separately (Survey of Client - Provider Communication in a Gynaecology Out-patient Clinic at
Municipal General Hospital, Unpublished).
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Box 2.19: Steps in validation exercise
•
Experienced investigators were recruited
•
Orientation for 3 days to observation checklist and interview schedule
•
Pre-testing of observation checklist
•
Pretesting of interview schedule
•
Inter-observer validation
•
Inter-interviewer validation
•
Observer-interviewer validation
•
Total of the 76 points (questions) were explored through the questionnaire and observation.
Exercise was carried out for 49 patients.
•
In all (49) schedules answers matched for more than 61 questions
•
In 27 schedules answers matched for more than 68 questions
•
Responses for 23 key questions were matched for observations and interviews.
•
In 36 out of 49 schedules responses matched for 21 or more questions
•
For 13 cases responses matched for 18 to 20 questions
•
For 1 case responses matched for 16 questions.
Tool
The semistructured pre-coded tool has following sections.
1.
Identifying information, reason for seeking help and reason for choosing the particular hospital
2.
Experiences regarding logistics
3.
Experiences regarding confidentiality during client-provider communication
4.
Experiences of undergoing PV
5.
Experiences regarding behaviour of medical, paramedical and non medical staff towards client and
accompanying person/s
6.
Whether doctor gave information related to condition for which the client sought treatment
7.
Whether the client was satisfied regarding availing services
Data Collection
A team of trained women investigators collected data. Team included five PID ANMs trained in interview
techniques with extensive experience of documenting gynaecological problems of women and two post
graduates in sociology who had diploma in para-socialwork. Five of seven investigators were married.
All the investigators were explained the objective, tool and the methodology of the study before the data
collection. All investigators were involved in the process of developing a codebook, coding, cleaning of
data. One of the investigators was also involved in the process of compilation of data. Such involvement
helped reduce the interpretation bias.
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; Women Centred Health Project I Report of the End Evaluation
Analysis
Responses that did not fit the pre-coded structure were listed, categorised and assigned numeric codes.
The coded data (quantitative) (numeric) was analysed using SPSS. Experiences and observations of the
investigators during data collection were documented and used where appropriate, for supporting the
quantitative data. Coded data was checked manually for any coding and interpretation errors. Cleaned
data was entered using SPSS and checked with mastersheets manually for data entry errors. Simple
frequency tables and cross tables were used for analysing and presenting the data.
The findings are presented under following sections.
1. Socio-economic background of respondents
2.
Reasons for seeking treatment
3. Client-provider communication
4.
Roles of various cadres of staff at VND hospital
5.
Experiences of clients regarding physical aspects of consultation
6.
Information given to clients and needs experiences by clients
7. Suggestions by clients for improvement of services
Findings
Socio-economic background of respondents
Women included in the study were between 14 to 62 years of age with more than 60 percent in the age
group of 21 to 30 years. Median age for women at VND hospital was 25 years and at MWD hospital was
26 years. 97% of women were married, seven were unmarried and nine were widowed. 87% of these were
homemakers. 23% could not read or write. 31% were educated till 8-10 standard and 28% till 5-7 standard.
These women came from households with average of four members with one earner (Table 29 Annexure 1)
Majority of earners were employed in the unorganised sector as semi-skilled / unskilled workers. Profile
of occupation of husband and other earners shows that 87% were small vendors and sold fruits, fish or
stitched clothes etc. Another 37% worked as unskilled unorganised workers in large industrial units.
More than 50% of earners had a monthly income of less than or equal to Rs.2000/-.
50% of women interviewed at VND hospital and 72% of those interviewed at MWD hospital were
accompanied to the hospital by either a relative or a friend. Of these 42% and 52% women interviewed at
VND and MWD hospital respectively were accompanied by their husbands. It was observed that those
who came alone to the hospitals were slightly older than those accompanied by husbands. Proportion of
illiteracy was more (29%) among those accompanied by husbands than who came alone. (Table 30
Annexure 1)
Reasons for seeking treatment
Five most commonly reported problems for which women sought help at the hospital were pregnancy
confirmation, problems during pregnancy, pain in abdomen and lower back, menstrual disorders reproductive
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| Women Centred Health Project I Report of the End Evaluation
tract infections, and complaints such as pain in limbs etc. The ranking of conditions differed slightly for
VND and MWD hospitals. More women had come to the gynaecology ORD in MWD for contraception
services whereas in VND RTIs and for D&C appeared among the five most commonly reported conditions.
Table 2.17: Reason for seeking treatment — Five most commonly reported conditions
VNDH n=292
MWD n=322
Problems during pregnancy (17 %)
Confirmation of pregnancy (17%)
Menstrual disorders (17%)
Pain in abdomen, lower backache (16%)
Other complaints* (12%)
Reproductive tract infections (10%)
D&C (10%)
Tubal Ligation (22%)
Confirmation of pregnancy (15%)
Pain in abdomen, lower backache (15%)
Menstrual disorders (14%)
Other complaints* (14%)
Problems during pregnancy (13 %)
Copper T insertion (13%)
Note: Only valid responses included
Multiple response
‘Other complaints include pain in arms, legs, etc.
Age wise distribution of reasons for seeking treatment shows that for the age group of 21 -30, problems
during pregnancy was the most commonly reported reason for seeking treatment at VND hospital. For
21-25 years age group the most commonly reported reason was confirmation of pregnancy. For older age
group pain in abdomen and lower back, menstrual disorders, RTIs and prolapse rank high.
A large number of women from the age group of 21-30 years had sought treatment at MWD hospital for D
& C and TL, Copper-T along with problems in pregnancy. For the older age groups RTIs and prolapse
uterus rank high among the reasons for seeking treatment.
Reasons for seeking treatment among unmarried women were menstrual disorders, pain in abdomen and
lower backache and widowed women sought treatment for prolapse, post menopausal bleeding and
menstrual disorders.
More commonly reported reason for seeking treatment replied by women who were accompanied by
husbands were confirmation of pregnancy or for investigation of missed periods, pain in abdomen and
lower back and for D. & C. (at VND hospital) and for TL, D. & C., pain in abdomen and lower back at MWD
hospital (Table 31 Annexure 1)
Reasons for choosing the hospital
The respondents were asked why they chose the particular hospital for treatment. More than 50% (51 %
at VND and 58% at MWD hospital) respondents reported to be ‘regular users’ of the hospital (“always
come here when in need for treatment.”). Another 15% at VND and 24% at MWD hospital sought treatment
based on suggestions by friends and relatives. 4% of respondents at VND and 10% at MWD hospital
were referred to these hospitals by both private and public sector facilities.
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Table 2.18: Reasons for choice of hospital
VND
n =292 (%
Reason
Near place of residence
Regular user
Inexpensive
Satisfactory past experience for self/others
Know staff member
All services available under one roof
Suggested by friends / relatives
Referred by private doctor / hospital / nursing home
Referred by municipal dispensary / health post / maternity home / hospital
Referred from camp conducted by Tata Memorial Cancer Hospital
24
51
6
1
1
1
15
3
1
<1
MWD
n=322 (%)
2
58
5
3
4
24
9
1
1
Note: Valid responses only
Multiple responses
Clien t-pro vider communica tion
Whether seated?
More than 95% respondents reported being seated while waiting as well as while history taking. 48% and
30% respondents at VND and MWD respectively reported being seated after the examination while the
doctor wrote prescription on the paper.
Whether doctor listened carefully?
Almost all (99%) respondents felt that the doctor listened to them while they told their complaints.
Maintaining eye contact while the women spoke, asking questions, and recording whatever women said
on the paper were perceived as the indicators of attentiveness by the examining doctor. (Table 32 Annexure
1) None of the respondents reported inability to answer any of the questions asked by the doctors.
However four respondents from MWD hospital and nine from VND hospital felt shy or hesitant to discuss
their problems with the doctor. Reasons for seeking treatment reported by these women include missed
periods / confirmation of pregnancy, for TL, and problems during pregnancy.
Box 2.20: Criteria of perceived attentiveness of doctors
Recorded all client said on paper
•
Asked questions
Looked at client while she talked
•
Asked questions in response to what client said
Communication with doctor
All respondents from both hospitals could answer all questions asked by doctor and could tell everything
they wanted to say to the doctor. 59 respondents reported that they were asked questions related to
sexual relations. 50 of these women reported being able to answer these questions.
Nine respondents reported that their communication with doctor was interrupted, in five of the cases
because of the doctor talking to other patients.
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| Women Centred Health Project! Report of the End Evaluation
18 out of 608 women interviewed for the survey reported feeling shy while talking to the doctor. Age
education, profile of these women do not differ from that of those who did not feel shy while talking to the
doctor. Reasons for seeking treatment did not vary from those reported by other women.
Number of cases where doctors probed to find out if respondent had' any other complaint, after she had
finished telling about her problems, was more in VND. 63% respondents from VND and 6% respondents
from MWD were asked by doctors if they had any other complaints
Except for one respondent from VND, no other respondents were asked at the end of consultation if they
had any doubts. 13% respondents each from VND and MWD reported clarifying their doubts. Of all these
respondents who asked for clarifications, only two respondents from MWD did not get clarifications from
doctors. (Table 33 Annexure 1)
Reassurance during PV
30% (79) and 22% (181) of the women interviewed at VND hospital and MWD hospital respectively
reported experiencing pain during the PV examination. Four women from VND hospital (5%) felt that the
doctor tried to lessen their discomfort during the PV examination. The doctor was/were reported to have
reassured the women (“don’t be scared”, “did it hurt?”, “won’t take long
”) during the examination.
This helped reduce the women’s fear during the PV examination. 32% respondents from VND and 11%
from MWD said that doctor talked to them during PV examination. However only 2% respondents from
VND and 1% from MWD felt that doctors made efforts to reduce clients’ fear of and anxiety about PV.
(Table 34 Annexure 1)
Around one third of those who underwent PV were told about the findings of PV. 24% in VND and 37% in
MWD were told the diagnosis or what was wrong with them / reason for their symptoms.
Perception about behaviour of the OPD staff
Respondents were asked if doctor, nurse or attendant at the OPD were rude to them, and whether they
shouted or insulted them. 12% respondents from VND found attendant to be rude and 7% said she
insulted them. Proportion of rude behaviour for doctors and nurses from both hospitals was low.
Presence of nurse / attendant during PV examination
In VNDH, nurse or attendant were present during 42% and 23 % the times respondents found them to be
polite and their presence was found to be reassuring and helpful.
Experiences of undergoing PV examination
93% of the women interviewed at VND hospital and 72% of those interviewed at MWD hospital were told
by the doctor about need to do PV examination. A large proportion of women who were advised PV knew
about it. (84% VND Hospital, 93% MWD hospital). It was observed that proportion of women reporting to
be scared while they went for PV was lesser (19%) among those who knew about what the PV examination
was. 57% of those who said they did not know what PV was reported being scared while going for the
examination. (Table 35 Annexure 1)
Age wise distribution of those who were scared showed that women from younger age groups (16-20,21 25, 26-30) were more likely to be scared while going for PV examination.
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Role of various staff at ORD
In VND it was doctors who gave instructions to clients about PV examination and what to expect during
PV and the nurse played a key role in ‘giving position’ for PV. In MWD this task was done by the
attendant.
Role of Nurse and Ayabai
30% of women interviewed at MWD hospital and 42% of those interviewed at VND hospital said that nurse
was present during the PV examination. This proportion seems less when compared to proportion of
women seen by male doctor.
Experiences regarding physical aspects of the OPD
The respondents were asked if they were seated while they waited at the corridor, for history taking, for
PV and while the doctor wrote prescription after the PV. This was regarded as a proxy indicator of
assessing whether the clients were comfortable while they waited and whether the medical, paramedical
staff respected them by offering a seat. It was observed during the pre-testing phase that women recall for
this was poor. (Unpublished). During the survey 95% or more women interviewed at VND hospital reported
being seated while they waited in the corridor, for history taking and for their turns at examination table.
However only 49% were seated while the doctor wrote the prescription after the internal examination. The
proportion of women reporting that they were seated was even less at the MWD hospital. At MWD
hospital 98 and 97% women reported being seated while waiting outside the OPD and while waiting for
their turn for history taking. 52% reported being seated while waiting for PV and 31 % were seated while
the doctor wrote prescription.
Women were also asked if they missed their turn (did the person behind her go ahead of her) for examination/
consultation. Eleven women reported missing turn while waiting in the corridor and six each reported
missing their turn while they waited for history taking and for PV examination. Poor management of
patient flow was one of the more common reasons reported for missing the turn. This is also supported by
the fact that those who missed the turn were not necessarily new to the OPD or very young or illiterate.
(Table 36 Annexure 1) The proportion of clients reporting that they missed their turn is very low as
compared to observations. This could be because the clients at municipal services have accepted chaotic
situations as a part of routine. The lack of awareness about one’s rights and apathy towards the situation
are causes of concern.
89% of the women interviewed at MWD hospital reported that they were rushed to get on the table. None
reported being rushed to climb down.
70% of women interviewed at VND hospital and 97% of those interviewed at MWD hospital reported
waiting time on the examination table to be less than five minutes.
Privacy during consultation and PV examination
Contradictory to the observation, very few women reported other patients crowding around the table during
consultation with the doctor. Out of 615 only nine women felt that their communication with doctor was
interrupted - mostly when doctors spoke to other patients.
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; Women Centred Health Project
I Report of the End Evaluation
Majority (99% at VND hospital and 95% at MWD hospital) felt that there was sufficient privacy while
undressing before the PV examination. Two women at VND hospital and 23 (11 %) at MWD hospital felt
that there was inadequate privacy during the PV examination. 8% of the interviewed women felt that
women sitting outside could see them while they underwent PV examination.
All except six women reported that their legs were covered during the PV examination. At MWD hospital
13% of women had similar experience
31% women from VND hospital and 71% from MWD hospital reported the toilet door to be without latch
- thus lacking privacy.
Table 2.19: Respondents’ perception of privacy during consultation for
gynaecological conditions
VND
MWD
Total
(%)
(%)
(%)
2(n=293)
1(n=322)
1 (n=615)
1(n=288)
5(n=322)
3(n=610)
Felt awkward while undressing
13(n=249)
20(n=195)
16(n=444)
Sufficient privacy for undressing
99(n=251)
95(n=198)
97(n=449)
99(n=257)
89(n=204)
95(n=461)
could see her while she was on examination table
4(n=257)
13(n=203)
8(n=460)
Legs covered during PV
98(n=257)
13(n=203)
60(n=460)
During consultation
Communication with doctor was interrupted
Other patients crowded around the table while respondent
spoke to doctor
In preparation for PV examination
Privacy during PV examination
Privacy during PV
Respondent felt that women outside the examination area
Note: Valid responses only
Reaction to male doctor
41% (84) of women interviewed at MWD hospital were examined by male doctor 93% (78) of them
reported feeling embarrassed. At VND hospital only two women out of 254 examined by male doctor felt
embarrassed.
Information to clients
8% respondents from VND and 10% from MWD said that they would like to have more information on their
condition, operation/ surgery advised to them, contraception and medicines prescribed.
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| Women Centred Health Project I Report of the End Evaluation
Table 2.20: Unmet need for information
Need more information
Need information on —
Total
VNDH
MWDH
8%
10%
9%
(n=293)
(n=305)
(n=598)
n=22
n=29
n=38
•
Condition / diagnosis
9
16
25
•
Investigations
2
4
6
•
Medicines
1
3
4
•
Operation
5
6
11
•
Contraception
5
1
6
•
Other
1
3
4
95% of the respondents expressed satisfaction about the services received at the hospital. Suggestions
for improvement of services were regarding improvement in behaviour of the staff and availability of medicines
and investigations from the hospital itself (Table 37 Annexure 1).
Box 2.21: Key issues identified through the baseline study for establishing
counseling centre at VNDH
•
Information needs of clients are not being met fully. Proportion of clients being told about
diagnosis or findings of examinations is very low and needs to increase.
•
Behavior of medical as well as para and non medical staff must improve.
•
Role for nurses and attendants needs to be defined
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| Women Centred Health Project I Report of the End Evaluation
Chapter 3
Evaluation
Rationale
Demonstrating model interventions for improvement in quality of care and mainstreaming successful
interventions was one of the objectives of the project. Therefore the project established mechanisms for
monitoring and evaluating effectiveness of all test interventions. Base line studies formed the first step for
implementing each of the test interventions. In 1999, the project conducted a mid term evaluation that
assessed effectiveness of the training inputs as well as the interventions introduced till that time. This
exercise was repeated again later on for the end of the project evaluation. Findings of the end evaluation
are compared with those from the baseline and mid term evaluation studies. Tools used in evaluation of
each of the test intervention and findings are presented at the end of the report.
Objectives of the end evaluation
•
To assess effectiveness of the interventions introduced by the project
•
To identify strategies that could be mainstreamed in the Public Health Department of Municipal
Corporation of Greater Mumbai.
•
To identify areas / components that require further support for sustainability.
Methodology for the end evaluation of the project
Planning for the end evaluation of the project began in 2001 with discussion among team members on
what aspects and how should the project be evaluated. In 2001 the midterm evaluation was planned
and carried out in a very planned and systematic manner. For the end evaluation the project followed
the framework developed at the time of the midterm evaluation of the project.
Box 3.1: Process for midterm evaluation
1)
A detailed framework was developed to evaluate each of the project objectives. Expected
outcomes, inputs given, indicators for evaluation, and sources of data were listed for each of
the objectives.
2)
The list of indicators and sources of data were reviewed and were observed to be related to
(1) clients’satisfaction
(2) providers’ perspectives about issues such as gender advocated by the project and
towards interventions introduced by the project, and
(3) effectiveness of services reflected in utilisation of these services.
Studies conducted for midterm evaluation
•
Interviews with key providers who
-attended TOT
- were participants at the various workshops conducted by WCHP
•
Interviews with administrators associated with WCHP activities
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It was observed that all the objectives of WCHP had been operationalised through the key interventions of
the project. Input and output indicators developed for the midterm evaluation were examined. Based on
the experiences of the midterm evaluation, while planning end evaluation the project started by listing
down most essential issues to be explored in client satisfaction, providers’ perspectives and utilisation
studies.
Key interventions by WCHP evaluated for end evaluation were
•
establishing gynaecological clinics at health posts and dispensaries
r
•
establishment of counseling centre at the gynaecology out patient clinic a the V N Desai hospital (a
i
•
development of gender sensitive, interactive IEC material, and
•
capacity building component of the project.
secondary general municipal hospital located in the H/East ward, one of the project wards
Small studies were designed to explore
(1) Experiences of clients related to services initiated by the project and the quality of these services,
(2) Poviders’ perspective on need for and effectiveness of the interventions and need for and feasibility of
continuing these
(3) Utilisation of gynaecology clinics at health posts and dispensaries and of counselling centre at VNDH
Details are presented in Table 1 Annexure 2.
4*
Steps for end evaluation
1)
Interview schedules were developed for exploring client satisfaction, providers’ perspectives and
utilisation of services.
2) A number of health care providers for each category were associated with the project in more than
one capacity. Health care providers were therefore grouped into various categories. Specific tools
were developed and administered to each of these categories to obtain relevant information. Efforts
were made to interview as many providers as possible.
3)
Information obtained through these tools was then segregated as per the objectives of the project.
V
For end evaluation key persons (health care providers) associated with the test interventions were identified.
Data was collected through focus group discussions and individual interviews using interview guides.
Clients’ satisfaction was assessed by conducting exit interviews with clients using services provided by
the gynaecology clinics at health posts/dispensaries and by the counseling centre at the gynaecology
out patient clinic of V. N. Desai Hospital in H/E ward.
Resources available at the health posts with gynaecology clinics were documented using the format used
for baseline study of facilities.
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Box 3.2: Studies conducted for end evaluation
Client satisfaction
•
Users of gynaecology clinics at health posts
•
Users of counseling centre at gynaecology out patient clinic at V N D Hospital.
•
Users of I EC material developed by the Project
Providers’perspectives on gender and women’s health, and key interventions of the project.
The following groups of providers were interviewed
•
Key trainers for Stepping Stones
•
RCH key trainers
•
•
Health care provider trainees of Stepping Stones
MPWs who were members of the Adolescent Boys Module Preparation Committee (MPC)
•
Administrators were also interviewed to explore feasibility of mainstreaming learnings of the project.
Utilisation Studies
•
Utilisation of counseling services
•
Utilisation of gynaecology clinics at health posts
Internal and External Evaluation
To ensure quality of data obtained through the studies and to prevent courtesy bias, individuals with
expertise in relevant fields were invited to conduct the studies for end evaluation of the project. The tools
were developed by the appointed experts using frameworks provided by the project. Information from
health care providers was obtained through group discussions and through in depth interviews. Data
obtained from the above-mentioned studies was analysed and is presented objective-wise.
Structure of the report
Findings of the end evaluation of WCHP are presented as per the specific objectives of the project. Each
subsequent chapter describes how each objective was operationalised, key activities related to the objective,
parameters used for evaluation of the particular objective and indicators used for assessment of effectiveness
of interventions.
Summary information from the analysis of quantitative data is presented as tables in the text. Detailed
tables are presented in the annexures. Tables in the annexures are referred to as 'annexed tables’ in the
text.
Map of the geographical area where WCHP was implemented, organogram of the Public Health Department,
and maps of layout of gynaecology out-patient clinic at V N Desai Hospital are presented as exhibits.
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Women Centred Health Project
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SECTION 2
FINDINGS OF END OF THE
PROJECT EVALUATION
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| Women Centred Health Project I Report of the End Evaluation
Chapter 4
Expansion of Range of Reproductive Health Service
Objective 1
To implement select reproductive health at the level of health post, dispensary
and post partum centre (PRC) by
•
increasing range of services on prioritised health problems
•
involving men
Following studies provided baseline information for assessment of objective 1
•
Review of health care facilities
•
A study of health care providers’ perceptions and attitudes towards women’s health and
quality of care provided by the municipal health care facilities
•
Exit interviews of users of municipal health services
Operationalising ‘increasing range of services on prioritised health problems’
Need expressed by the participants of the RID study for comprehensive reproductive health care near
their homes prompted the Women Centred Health Project’s efforts for strengthening primary level health
care services. The project responded to this challenge by trying to initiate gynaecology clinics at all
health posts and dispensaries in the two project wards. Ultimately the project was able to start gynaecology
clinics at eight health posts from the two project wards as well as from three other wards. Initially the
project focussed on increasing availability of services for selected four conditions, namely -1) menstrual
disorders, 2) ante-natal care, 3) reproductive tract infections and 4) contraception.
Operationalising ‘involving men’
Women interviewed during the RID project felt that providers should talk to men partners especially in
cases of sexually transmitted infections and where women were advised to abstain from intercourse for
medical reasons. The study also showed that women did not have freedom to make decisions about their
reproductive health and at times could not negotiate with their husbands. Women believed that health
care providers could play a key role in convincing the men about importance of their role in women’s
reproductive health.
Discussions with health care providers showed that the health care providers especially men health care
providers did not see a clear role for themselves in dealing with spouses of women health seekers. This
prompted WCHP to explore strategies for increasing men’s involvement in women’s reproductive health.
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The project aimed to explore ways to enhance men’s willingness to cooperate in prevention and treatment
of reproductive and sexual health problems that their partners might suffer from.
WCHP regarded men’s involvement in reproductive health of women with caution. While shaping the
activities for increasing men’s involvement in women’s reproductive health the project has been careful to
ensure that such information to men or men health care workers will not result in women losing control
over their bodies and decision making processes involved in reproductive health issues. Second, WCHP
visualised men’s involvement in reproductive health as having a broader scope than the commonly
understood ‘male involvement is equal to promotion of vasectomies’ notion. While the project recognised
that men’s own reproductive health needs are a part of ‘men’s involvement in women’s reproductive
health’; considering the scope of the project and resources available’to it, the project chose to work with
male health workers from PHD of MCGM. This was considered as a pre-requisite for involving men from
the community. This choice of strategy was in line with the wider objectives of the project to expand range
of RH services, to improve quality of RH care at primary level health care facilities and to ensure
mainstreaming by building capacity of municipal health care workers.
Box 4.1: Multipurpose Workers - Male: A Profile
•
Minimum required qualification: SSC pass + Sanitary Inspector (One year Diploma)
•
On job training: related to all national health programmes, none to enable them to work with men
Efforts of the project towards increasing men’s involvement in reproductive health can be broadly categorized
into -1. Research, 2. Capacity building, and 3. Interventions. Gender sensitisation of men to understand
the relation between gender, patriarchy, power, and reproductive health was placed at the centre of all
efforts regarding men’s involvement. The project focused on men health care workers as potential change
agents. MPWs as representatives of a highly male dominant Indian society and those placed on lower
rungs of a highly hierarchical public health care delivery system were a true challenge to work with. This
strategic decision of the project resulted in minimal interaction and intervention with men from community.
Parameters and indicators used for evaluation of gynaecology clinics at health posts
End evaluation of gynaecology clinics at health posts and dispensaries was aimed at exploring the
effectiveness of the clinics in meeting reproductive health needs of women by provision of women-centred,
gender sensitive, comprehensive and quality health care services. The clinics are evaluated from the
clients’, providers’ and administrators’ perspective.
Evaluation of the gynaecology clinics is based on
•
Utilisation of these clinics for reproductive health conditions as compared to health posts without
•
such clinics
Interviews of clients on perceived usefulness of these clinics and on quality of care (Clients’ perspective)
•
Interviews with providers to explore their perception about usefulness of these clinics, and about feasibi
lity of continuing the clinics beyond the duration of the project (Providers’ and administrators’ perspective)
•
Project experiences - output as compared to input
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Women Centred Health Project I Report of the End Evaluation
Box 4.2: Evaluation of Objective 1: Increasing range of prioritised reproductive
health conditions
Input Indicators_________________ Output Indicators____________________________
• Number of staff trained in • Number of facilities providing reproductive health
Number of health care facilities where •
services
Increased awareness in the community about
essential resources are made available
availability of services
Number of facilities with monitoring •
Increase in number of persons using services
reproductive health
•
•
and supervisory systems in place
•
•
Increased client satisfaction
Increased provider satisfaction
•
Improvement in skills of staff as seen through
•
technical supervision
Increase in number of men actively participating in
partners’ treatment seeking OR Increase in partner
notification and in number of men jointly seeking
treatment with their women partners
•
Increase in number of facilities using standard
treatment procedures (following guidelines, using
manuals etc.)
Inputs and the process
Inputs were provided to the health care providers for improving their communication and counselling skills
and sensitising them to the social aspects of reproductive health condition. Along this course the project
realised that training and reported motivation of the health care providers at the primary level health care
facilities was not enough for initiating gynaecology clinics at the health posts and dispensaries. Though
the health posts claimed to be already providing gynaecological services, essential equipment and
instruments were not available in many of the health posts and dispensaries from the project wards.
Inability of the health post staff as well as of the administrators in organising resources delayed the initiation
of provision of services at the primary level. Following a survey in 2000 of the resources available at the
health posts and dispensaries, a list of prerequisites for starting gynaecology clinics, was developed.
In addition to providing refresher training in clinical and social aspects of selected reproductive health
conditions to medical officers and other staff at the health post, the project mobilised resources from
within the MCGM (e.g. gloves, steriliser, and speculum) and when this was not possible purchased the
equipment for the health posts (e.g. stethoscopes, BP instruments, steriliser, wash basin, shadowless
lamp, etc.) All gynaecology clinics were provided curtains for ensuring adequate privacy and assisted in
cleaning/ painting of the facilities. Non-availability on MCGM schedules of medicines required for treatment
of gynaecological conditions was another problem faced by the health care providers. The Project liaised
with Mumbai District AIDS Control Society (MDACS) to ensure regular supply of these medicines. Tp
ensure the quality of services provided through these clinics, the project arranged with gynaecologists
from nearby Post Partum Centres and maternity homes to visit the gynaecology clinics once a month to
review case records maintained by the medical officers and to discuss cases.
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Box 4.3: WCHP’s contribution to initiation of gynaecology clinics at health
posts and dispensaries
•
Refresher training to clinicians
•
Refresher training to ANMs and MPWs
•
Training to CHVs
•
Refresher training to laboratory technicians
•
Stethoscopes and BP instruments
•
Drugs from MDACS — WCHP liaised with MDACS
•
Soft boards for display of IEC
•
Stationery for maintaining records
Curtains for privacy
Wash basin
Shadowless lamp
Instrument trolley
Hot plate
Steriliser
Cleaning/painting/ sprucing up of
health posts
Awareness generation in the
community through street plays
performed by trainee social workers
Output and achievements
With focused inputs and continuous liaisoning with administrators the project succeeded in initiating
gynaecology clinics in three out of nine health posts from G/N and one out of eight health posts from HZ
E. Vacancies of medical officers’ positions resulting in one full time medical officer managing six health
posts in H/E ward, was the biggest obstacle in initiating gynaecology clinics in this ward. Efforts to
initiate gynaecology clinics in G/N ward reinforced the understanding of the project that motivation of the
staff is the most important pre-requisite for initiating gynaecology clinics.
When the MOsH from H/E and G/N with whom WCHP had worked for initiating the first gynaecological
clinics in respective wards were transferred to E and Awards respectively, one gynaecology clinic each
was initiated in these two wards. Health care providers and administrators from K/E ward where the
project office was located showed interest in initiating gynaecology clinics and these were started in two
health posts.
Studies conducted for the midterm and the end evaluation showed increased awareness among the
community about the services provided by the gynaecology clinics. This was also reflected in increase in
the utilisation of these services. Review of case notes maintained by the medical officers at the gynaecology
clinics found the clinical practice to be of satisfactory quality.
Work with men though initiated from 1997 gathered momentum only in 2001 after which a series of
training workshops were organised for men health workers from the PHD. Men’s involvement component
of the project for increasing men’s involvement in reproductive health focused primarily, on capacity
building activities for MPWs. A draft training module on reproductive and sexual health for out of school
adolescent boys was developed by a small group of MPWs and male CDOs. Since these activities were
still in preliminary stages these were not evaluated during the end evaluation of the project. A chronological
listing of the project’s activities related to men’s involvement in women’s reproductive health (Table 1) and
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investment in human resource for increasing men’s involvement (Table 2) is presented in Annexure 3.
Detailed documentation of the project’s activities (Working with Men for Increasing Men’s involvement in
Reproductive Health: Experiences of WCHP, 2004) and the training module on reproductive and sexual
health for out of school adolescent boys have been published.
End evaluation of gynaecology clinics at health posts / dispensaries
Utilisation of the gynaecology clinics at health posts/dispensaries
On average four to seven women came to the clinic for treatment of reproductive health conditions. This
number is very small compared to the expected number of clients. Poor outreach could be one of the
reasons. This conclusion is supported by the fact that during the Family Health Awareness Campaign
(FHAC) of MDACS, utilisation of services at the same clinics ranged from 16 to 102 for 15 days of the
campaign.
Table 4.1: Utilisation of gynaecology out-patient clinics at health posts and
dispensaries
FHAC 2003
May 2003
April 2003
Health Post with
gynaecology
No. of
Total
Average
No. of
Total
Average
Total no.
Average
clinic
clinics
no. of
no. of
clinics
no.
no. of
Clients
no. of
clients
clients
Clients
clients
clients
per clinic
per clinic
per clinic
S V Nagar
3
11
13
4
4
4
Tarun Bharat
57
3
16
1
31
2
Sambhaji Nagar
Colaba
4
18
4
Gulabai
2
5’
3
1
2
2
34
2
Welkarwadi
3
23
7
3
23
7
70
4
Shastri Nagar
4
53
13
2
17
9
63
4
Tadwadi
3
7
2
2
6
3
102
7
It is important to note that though the number of clients availing services at gynaecology clinics is small,
it is an improvement from the number availing of services at health posts and dispensaries before the
projectproject actively intervened for initiation of gynaecology clinips. Following the clinicians’ training and
before the projectproject facilitated physical resources, between the eight health posts and ten dispensaries
from G/N ward, on average six cases of gynaecological and obstetric conditions were reported per month.
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Table 4.2 : Gynaecological and obstetric cases reported by eight health posts and
ten dispensaries in G/N ward
__________ Health posts (8)
November ’98
December ’98
January ’99
Total
Total female
registrations*
382
402
296
1,080
Dispensaries (10)
Gynaecological
cases reported
40 (10%)
47 (12%)
30 (10%)
117 (11%)
Total female
registration
18,571
18,623
14,893
52,087
Gynaecological
cases reported
114 (0.6%)
111 (0.6%)
88 (0.6%)
313 (0.6%)
Note : Percentages are calculated on ‘total female registration’ for respective facilities. Choice of time period is
random.
‘Includes female children.(Total number of gynaecological cases reported in G/N : 117+313= 430
Total number of health care facilities reporting the data : 8+10=18
Period over which this data is reported : 3 months
Average number of working days per month: 25
Average number of gynaecological cases per month reported for 18 facilities of G/N: 6)
Perceived usefulness of the clinics: Clients’ perspective of quality
of care
For end evaluation exit interviews were conducted with 50 women seeking services from six health posts.
Due to low attendance of clinics for two months previous to data collection, part of data was collected
during the FHAC. This might have influenced the reasons for which women seek services and the reliability
of responses to questions such as “how did you know about services provided through the clinic?”
Profile of Clients at gynaecology clinics
25 out of 50 clients interviewed for end evaluation were between 21 -30-years of age. Majority women were
married, not employed, and came from families with monthly income of less than Rs.4000/-. This profile
has remained unchanged since the midterm evaluation in 2002. The sample also covered seven women of
age more than 40 and two adolescent girls who sought services at the clinic. (Table 3 Annexure 3)
Most commonly reported reason for seeking treatment is for white discharge. (Table 4 Annexure 3) One
woman had approached the clinic for treatment on infertility. For 25 out of 50 women interviewed for end
evaluation, gynaecology clinic at health post was the first contact with health care system for present
complaints. During midterm survey this proportion was 15 out of 45 women. 34 out of 50 women were
advised to seek treatment at the clinic by CHVs or other health post staff. Rest 15 were advised by friends
and neighbours. (Table 5 Annexure 3)
Respondents were asked to name services that they knew were provided through the health posts. Ten
out of the 50 women were aware (prior to consultation with doctor on the day of interview) of availability of
gynaecological services at the health post. During midterm survey only two out of 45 women had mentioned
about gynaecological services.
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Table 4.3: Awareness of services available at the health post
Total
Services available at health post
Family planning
Treatment for TB
ANC
Gynaecological services
Immunisation
Midterm
n=45
End evaluation
n=50
Midterm
13
End evaluation
10
Midterm
1
End evaluation
19
Midterm
2
End evaluation
7
Midterm
2
End evaluation
10
Midterm
3
End evaluation
36
Midterm
Adolescent clinic
Cough/cold, other treatment
End evaluation
4
Midterm
3
End evaluation
Privacy, respectful behaviour and information about diagnosis and treatment were regarded as indicators
for quality of care - from clients’ perspective. All 50 women felt that doctors listened to them attentively
while they talked about their health conditions. Asking questions in response to what the respondent
(woman) said, maintaining eye contact and giving undivided attention were regarded by women as indicators
of ‘listening attentively’. All women reported that they could speak freely with the doctor. 25 women had
an internal examination and all of them expressed satisfaction about privacy. 46 out of 50 women received
medicines from the health post. Two women were given medicines for their husbands or male partners but
the male partners were not asked to see the doctor.
Providers’ perception about gynaecology clinics
A focus group discussion was conducted with seven ANMs and two medical officers from health posts
and dispensaries with gynaecology clinics. In the word association exercise conducted for ANMs, they
came up with following associations for ‘gynaecology OPD’: regular medicine, good doctor, women, male
patients, follow-up, ANC, PNC and immunization. Some of these seem to be ideal notions of what the
gynaecology clinics ought to have, or do, because in subsequent discussion the ANMs clearly said that
they were unable to follow up patients in the community or ensure male involvement. Even with probing
the ANMs could not specify what they do to increase awareness among women about the gynaecological
services provided at the clinic. The ANMs said that they did not feel like motivating women because they
were not sure whether the doctor would be there when they referred the client. Burden of record keeping,
involvement in other national programmes such as RNTCP and Pulse Polio makes it difficult for them to
do community outreach work or sustained follow up.
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Usefulness of clinics to clients
The ANMs felt that women who use services at the clinics save time, when they are spared the necessity
of queuing up in a large hospital, and money, when they receive medicines from the clinics instead of
having to buy them from shops. Also, being closer to home, they save on transport expenses. CHVs have
rapport and women do not feel shy to talk about reproductive health conditions because of familiarity and
trust. Non-availability of woman-doctor was cited as the main reason for poor utilisation of the services.
Records maintained by the project and reports submitted to the MDACS about supply of drugs to health
posts and about utilization of these drugs by conditions show regular supply of medicines to the clinics.
The ANMs believed that the clinics have not made a huge difference to women. They strongly felt that if
there was a “good room”, assured medical supplies and a woman doctor, women from community would
:..t;
£
come. However it has been observed that a male doctor is not totally unacceptable to women. In H/E ward
where one woman FTMO looks after six health posts, on a number of occasions, a male medical officer
from attached dispensary conducted the gynaecology clinic in her absence.
Obstacles to mainstreaming
Two medical officers who managed gynaecology clinics were interviewed. The doctors agreed that utilisation
of services was low though there has been a gradual increase in number of women seeking treatment at
these clinics. They felt that ‘it typically takes time for services in MCGM to take off. Vacancies among
doctors affect regularity of the clinics. Long absence of doctors from health posts and staff shortages
affect the credibility and disrupts the momentum and continuity of services. FTMOs feel that the CHVs
are key to the success of the gynaecology clinics at health posts since they know the geographical area
well, represent the health system at community level, and hence are pivotal to how the relationship
between the community and health post evolves.
Quality of care provided by the clinics
The ANMs interpreted quality in health service delivery as being defined by involvement of men, drug
availability, and good rapport between the health providers and the patients. Particularly in the context of
the gynaecology clinics, they felt that quality completely depended on availability of a lady doctor who
talks and behaves well (“talks nicely with patient without being hi-fai”). They also felt that the health post
should look clean and neat so that the patients feel good. They aopined that equipment at the health post
is not well maintained and were critical of the health post attendant who did not sterilize the instruments
properly. When asked whether physical structure was more important from a quality point of view, the
group unanimously said the attitude of the doctors was more important.
These views on quality were echoed by the medical officers who felt that basic infrastructure like water
1
and chairs should be in place and the health post should look neat and ‘posh’. FTMOs did not see the
■i-.
r
clinics as a new activity as they always attended to women coming to health posts with reproductive
health problems. Both ANMs and medical officers believed that sustainability of gynaecology clinics
hinges on availability of a woman doctor and on availability of regular drugs supply. The medical officers’
suggestions for ensuring sustainability were to do ‘propaganda’ through television and local cable network.
Perceived contribution ofWCHP
The doctors also felt that CMEs were important because they help update their knowledge about newer
drugs and medical procedures. Availability of medicines, privacy and equipment and instruments required
for internal examination are a direct result of the projectprojects interventions.
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Experiences of WCHP — output as compared to input
From the beginning of the initiative for establishing gynaecology clinics at health posts, Women Centred
Health. Project was clear that success of this initiative would rely on active participation of and therefore
ownership by PHD of MCGM. The project contributed to the process of expanding the range of reproductive
health services by providing training and ensuring that prerequisites were in place. The response from the
system was slow and lukewarm.
Despite two training workshops for laboratory technicians from upgraded dispensaries the project was not
successful in motivating them to conduct basic investigations essential for diagnosis of RTIs at the
dispensary level. A lot of time was spent in conducting a time motion study to explore the technicians’
claim that they were overworked and hence would not be able to take on more responsibility. Vacant
posts of laboratory technicians and laboratory assistants were the obstacles in initiating investigations at
the level of dispensaries.
Delay in mobilisation of resources within the PHD delayed implementation of expanded RH services
through health posts affected the enthusiasm of the providers.
Administrative difficulties in handing over the responsibilities for insuring drugs supply by liaisoning with
MDACS, technical as well as administrative supervision and timely repair of equipment poses serious
concerns for sustainability of the initiative.
Technical supervision at regular intervals is essential for sustainability of the initiative and for ensuring
quality of care. For the duration of the project, gynaecologists from nearby post partum centres were
involved in supervision of the gynaecology clinics. Closure of PPCs and non availability for funds for
providing for travel costs of the supervisors beyond duration of the project could result in discontinuation
of supervisory visits. Official arrangements need to be made through the PHD for continuation of technical
supervision.
Women Centred Health Project had envisaged a more active role for the MPWs resulting into activities for
increasing men’s involvement in reproductive health. Given the fact that, prior to WCHP training workshops,
MPWs had not been trained to discuss sexual and reproductive health issues with men, the project
anticipated slow pace of activities. However, lack of efforts towards increasing men’s involvement through
increased I EC activities (on reproductive health and men’s role in it) for men and follow up (if advised by
medical officer and consented by women clients) of spouses of women seeking treatment for RTIs is a
lacuna in the ‘increasing range of services at primary level’.
Efforts put in by the project for capacity building of MPWs were justified by the development of a training
module on reproductive and sexual health for out-of-school adolescent boys.
By initiating the gynaecology clinics at health posts WCHP demonstrated feasibility of expansion of
range of services with minimal inputs. Sustainability of these clinics beyond the duration of the project
depends on ownership by the health care providers and administrators from the Public Health Department.
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Box 4.4: Excerpts from report of external evaluator
...I met large groups of CHVs in two of the three OPDs that I visited. They described case histories of
patients they had brought to the OPD, and talked about their confidence and comfort in talking about
sexuality and reproductive health issues to women in the community.
“After the training we know better, we explain better to the women so they come (to the gynaecology
OPD).”
one client I spoke to had come fora check up one week after she had had Copper - T inserted.
She did not belong to the ward in which the health post was located, but has come because she
had heard good things about it from a relative who is a user of the health post. She appreciated
the information she received on different methods of contraception, the careful ‘check-up’ by the
doctor before insertion of Copper - T and the advise given to make a return visit the next week.
She felt that the care she received was much better than ‘private’....
Discussion
High utilisation of services during FHAC and increase in number of women who were aware of gynaecological
services provided through health posts, and the fact that for half of them gynaecology clinics were the first
point of contact with the health care delivery system are positive signs that indicate the need for such
services and increased reach among the community. Low utilization on non-campaign days however is a
cause for concern and needs to be examined. More efforts on part of.MPWs are required to reach out to
men partners of women seeking treatment for reproductive tract infections. Sustainability of these clinics
depends primarily on ownership by the Public Health Department and establishment of systems for
routine monitoring and review of functioning of the clinics.
Box 4.5: Salient achievements of WCHP
•
Gynaecology out-patient clinics were started at eight health posts and dispensaries with
minimal financial inputs by the project.
•
Utilisation of gynaecology clinics increased after CHV training, thus emphasising role of
•
CHVs in health care delivery.
Lessons learnt from project in starting gynaecology clinics were incorporated in the training
module for Urban RCH and were shared with all health care providers of the Public Health
Department.
Claims of health care providers that they have always been providing care for reproductive health conditions
may be true but are not reflected in the MIS reports generated by the MCGM. A rapid review of health
posts and dispensaries outside Project wards has shown that reach of RH care services in most of the
facilities has been limited to women seeking Cu-T. However reaching out to community through CHVs
and assigning a specific time for gynaecology clinics has resulted in increased awareness about availability
of services. This is a step towards mainstreaming of this activity.
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Collaboration with MDACS, a large HIV/AIDS agency proved valuable in ensuring adequate and timely
supply of drugs required for treatment of reproductive heath conditions and thus increasing the credibility
of the health posts.
Large number of vacancies for the medical officers and irregularity of services resulting from inadequate
staff and inadequate essential supplies such as drugs pose the biggest challenge for sustainability of the
gynaecology clinics at primary level facilities.
Box 4.6: Key issues emerging from the end evaluation of activities for
expansion of range of reproductive health services
•
Increase in utilization of services provided by the clinics indicates increased awareness
among the community
•
Focused demand generation activities can result in large increase in number of women availing
of the services as in FHAC
•
Service provision and demand generation should be simultaneous and should be given equal
importance. CHVs play a key role in reaching out to women
•
Absence of medical officer from clinic frequently and for long duration affects credibility of the
facility
•
Role of ANMs and MPWs regarding the gynaecology clinics needs to be further clarified for
increased ownership
•
Efforts should be made to reach out to women beyond the reproductive age group and to
adolescent girls
Suggestions for mainstreaming gynaecology clinics at health posts and
dispensaries
•
Functional integration of health posts and dispensaries located in the same premises with placement
of atleast one female doctor at the integrated facility.
•
Vacancies at the health posts, especially of medical officers need to be filled. Absence of medical
officers conducting the clinics can demotivate the clients from approaching the clinics.
•
Refresher training on treatment of gynaecological conditions should be given to all health care providers
at regular intervals.
•
Availability of adequate quantity of appropriate drugs is essential for credibility of the clinics. The
indenting and procurement procedures of the MCGM should be reviewed and modified to ensure
regular supply of drugs. Alternatively a system for consistent, regular supply of drugs should be
•
identified.
There is a need for developing a sustainable system of monitoring involving consultant gynaecologists
from maternity homes and post partum centres. Records should be maintained using the monitoring
checklists. MIS for MCGM needs to be modified to include data on number and nature of conditions
treated at gynaecology clinics at health posts and dispensaries. A system of audits of clinical procedures
should be implemented.
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Women Centred Health Project I Report of the End Evaluation
Chapter 5
Quality Assurance Mechanism
Objective 2
To establish and implement quality assurance mechanisms including
communication, treatment and referral procedures.
Following studies provided baseline information for assessment of objective 2
•
•
Review of health care facilities
A study of health care providers’ perceptions and attitudes towards women’s health and
quality of care provided by the municipal health care facilities
•
Exit interviews of users of municipal health services
Operationalising ‘Quality Assurance Mechanisms’
Quality Assurance efforts of the Women Centred Health Project were primarily guided by the findings of
the RID study where women users of municipal health care services identified inadequate range of
reproductive health services at community level, poor client provider communication, inadequate information
and counselling services and exclusion of men from the counselling process as factors affecting the
quality of municipal health care services. Respondents from the RID study felt that their right to information
was not acknowledged by the health care providers. The findings of the RID study indicated the need for
improvement in quality of care provided at the municipal health care facilities.
Baseline studies conducted in 1997 corroborated the findings of the earlier study. Exit interviews of 367
clients using the health posts, dispensaries, urban health centre, maternity homes, post partum centres
and a secondary hospital were conducted to explore client satisfaction about municipal services. A large
majority (88%) of clients interviewed for the baseline study expressed satisfaction about the services they
received and 92% said that they would visit the facility in future. 25 respondents expressed dissatisfaction
and said that they would not seek services at the health care facilities in future. Though the number of
clients saying this is small, reasons stated for this gave an idea about clients perception of quality of
care. Inconvenient timings and location of the facility, perceived poor quality of care and disrespect shown
by health care providers were the reasons mentioned by these respondents. The clients in the same
study were asked their reasons for not asking questions of the doctors. Responses indicated poor
communication between providers and clients.
Another baseline study (1997) was conducted to explore the providers’ perspectives on quality of care. 70
health care providers from 13 health care facilities were interviewed. ‘Client satisfaction’ was reported by
these providers to be one of the indicators of good quality of health care. The providers felt that client
satisfaction was dependent on ‘availability of drugs (26%)’, ‘proper examination of patients (20%)’, ‘availability
of a wide range of services (19%)’, and ‘friendly staff behaviour (17%)’. The providers also expressed need
for improving quality of care provided by the municipal health care facilities.
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| Women Centred Health Projectl Report of the En d E v a 1 u a t i o n
Efforts for introducing QA into the PHD centred around a series of QA workshops aimed at sensitising a
cross section of health care providers to the concepts of quality of care and quality assurance. Participants
of the first Quality Assurance Workshop organised in January 1997 identified poor client-provider
communication, inadequate referral system and non-availability of drugs to clients as factors affecting
quality of health care services and chose to work on these issues with the project. Each of the test
interventions were reviewed at subsequent QA workshops and providers’ perspective on perceived
effectiveness of such interventions was explored during the midterm evaluation. At a later stage (in 2000)
the project initiated a counselling and information centre at the gynaecology out patient clinic at V N
Desai Hospital in H/E ward. Through this centre the project has operationalised its vision related to
women-centred, empowering information provision and counselling services.
Following the fourth QA workshop a group consisting of representatives of various cadres of health care
providers was formed to develop a QA manual for the PHD that would spell out the working definition of
QoC and QA for PHD. The group was dissolved because the participants of the group believed that QA
was a ‘foreign’ agenda and refused to own what they said about QoC and QA. For the sixth QA workshop
with help of a group of senior administrators from PHD, the project developed a draft Charter of Patients’
Rights and Responsibilities that emphasised the commitment of the municipality towards clients. A
Ranking System that would acknowledge the contribution of each health care provider and build team
spirit at the primary level health care facilities was developed. A background paper on need for developing
a QA policy for PHD was discussed in the sixth QA workshop. The ranking System and the Patients’
Charter could not be finalised due to various problems.
Results from the midterm and end evaluation for each of the interventions related to QA are presented
here.
Parameters forevaluation of quality assurance interventions
Interventions for improvement of quality of care were primarily from the clients’ perspective though the
project also incorporated providers’ perspective through interventions such as modification of lay-out of
ORD. The Project has always addressed quality of care from a rights perspective. The evaluation was
therefore aimed at assessing effectiveness of the interventions in ensuring quality health services to
clients that ensure the clients” right to reproductive health care and result in provider as well as client
satisfaction.
Evaluation of QA interventions is based on
•
ability of the intervention to meet expressed needs of clients
•
effectiveness of the intervention in sensitising the providers to rights perspective and client-centred
approach
•
increase in client and provider satisfaction
•
ability of the interventions to build capacity of the health care providers to sustain the activities
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! Women Centred Health Project I Report of the End Evaluation
Box 5.1: Evaluation of objective 2- Establishing and implementing quality assurance
mechanisms
Output Indicators
Input Indicators
Client - provider communication and counselling
•
•
Number of personnel trained in commu
nication standards are displayed
nication and counselling skills
•
•
Number of facilities where commu
•
Systems developed for ensuring
Number of centres where staff is
improvement in communication and
trained, IEC material for counselling
counselling skills
is available and where counselling
Monitoring system for ensuring monitoring
services are provided
of communication and counselling
•
Number of personnel trained
services
•
Number of clients using these services
•
Tools developed to facilitate
improvement in quality of care and
processes initiated for QA
Key interventions for introducing quality assurance mechanisms in the Public Health Department of
MCGM were about
• improving client-provider communication in gynaecology OPD
• addressing counselling needs of clients and spouses at gynaecology outpatient clinic at V N Desai Hospital
•
•
improving referral system
drug monitoring exercise to explore pilferage of drugs at the level of primary level facilities as a main
•
cause for non-availability of drugs
forming groups of health care providers and administrators to spearhead the systematic efforts for
•
mainstreaming QA into the PHD
sensitising the public health system to patients’ rights and prompting them to acknowledge the same
through development of Patients’ Charter of Rights and Responsibilities and a QA policy for the PHD
•
pilot testing of tools / checklists for assessing quality
Evaluation for each of these interventions is presented in this chapter.
Client-Provider Communication
Pre-intervention
Exit interviews of users of municipal health services (1997)
Participants of the first QA workshop reported large number of clients per medical officer resulting in
limited time available to talk to clients, absence of counselling services, inadequate information services
and at times language barriers as factors affecting quality of client-provider communication.
Focus group discussions with men, women, adolescent girls from community also documented
disrespectful staff behavior, lack of information about treatment, lack of couple counselling for contraceptives,
infertility and reproductive tract infections.
c
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| Women Centred Health Project I Report of the End Evaluation
A study was conducted in April 1997 to document users’ perception about municipal health care facilities.
The clients interviewed for the study reported rude behaviour and crowded out patient clinics as reasons
for their inability to clarify their doubts with doctors.
Observations of client-provider communication in gynaecology outpatient clinic at a secondary hospital
identified adverse client-provider ratio, lack of coordination between providers, inconvenient physical layout,
language barrier and social distance between the providers and clients to be the key factors influencing
quality of client-provider communication.
The providers who participated in the first quality assurance workshop believed that it was within the
powers of the health providers concerned to bring about improvement in communication with clients. This
issue was selected for development and pilot implementation of test intervention.
Exit interviews of clients at V N Desai Hospital and M W Desai Hospital (2001)
A survey was conducted at VND and MWD in 2001 to document the extent to which information was given
to clients seeking services at gynaecology outpatient clinics of these hospitals. 293 and 322 women were
interviewed at VND and MWD respectively. It was observed that large proportion of respondents could talk
openly to doctors about their complaints and could answer questions asked by doctors. However the
communication between the clients and providers in the clinic appeared to be one-way with clients playing
attentive listeners. The communication by doctors also did not contribute to lessening fear or anxiety
regarding PV examination. 38 and 33 percent respondents were told about findings of PV examination at
VND and MWD respectively. It was also observed that at the end of the consultations respondents still
had questions regarding why they had the symptoms. 24 and 33 percent respondents from VND and
MWD respectively were informed about diagnosis or what was wrong with them. 13 percent respondents
clarified their doubts with doctors by asking questions at the end of the consultation process. In all but
two instances in MWDH the doctors answered the questions asked by clients. Communication with
nurse or attendant at the outpatient clinic was minimal and was restricted to instructions for ‘taking
position’ for PV. (Table 33 Annexure 1)
Interventions by WCHP
After discussing the probable ways of addressing the problems of client-provider communication the
project implemented following interventions
•
A checklist was developed for monitoring of client-provider communication and was pilot tested at a
maternity home. This was also used at a later stage in the gynaecology outpatient clinic of a secondary
hospital before initiation of the counselling centre.
•
Feedback to staff about their communication style.
•
Sessions on ‘communication and counselling skills’ were included in all training workshops
conducted by the project and in the in-service training conducted by the PHD for all levels of health
care providers.
•
Training in Counselling skills for contraceptive and reproductive health counselling to health care
providers from health posts.
•
Initiation of counselling centre in gynaecology out patient clinic of V.N. Desai Hospital.
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Capacity building activities aimed at improving client-provider communication are discussed in Chapter 7.
Establishment of the counselling and information centre was an achievement for the project and became
an independent major activity. Evaluation of the counselling component is presented separately.
Midterm (1999)
During midterm evaluation a questionnaire was administered to understand the effects of the exercise
(peer observation using the communication monitoring checklist and feedback) on health care providers
and their opinion about usefulness of such an exercise. Thirteen providers who had participated in the
earlier exercise either as observer or observee were interviewed for the midterm evaluation. The questionnaire
also explored the providers’ perceptions of‘good communication’. (T-7.1 Annexure 7)
Data showed that for providers ‘understanding patients’ needs and responding to them accordingly’ is
good communication. Nine of the 13 respondents found the communication monitoring exercise useful.
11 respondents were of the opinion that periodic observations would help in bringing about improvement in
their communication with clients. However, opinion about the effect of this exercise on ‘self’ was divided.
12 out of 13 respondents answered this question. Six felt that the exercise did bring about some change
in them, they ‘realised the need for providing good quality care to patients' and felt that they ‘became
aware of the problem faced by the patients’. The same respondents reported that ‘such checks make
them conscious of their behaviour (and hence bring about a positive change). Five respondents felt that
the exercise did not benefit them as ‘their communication was good from the beginning'.
Respondents from the midterm evaluation felt that use of peer observation ‘might not bring out the true
picture as observers might be less critical about their colleagues’. Some participants reported that the
knowledge that they were being observed made them conscious of their behaviour and they then put on
their best behaviour thus portraying a picture that was far from ‘normal / routine’.
End evaluation (July 2003)
Effectiveness of all interventions for improvement of client-provider communication was evaluated through
•
Exit interviews of users of gynaecology clinics at health posts
•
Exit interviews of clients using services at the gynaecology out patient clinic at V. N. Desai Hospital
Exit interviews of users of gynaecology clinics at health posts (2003)
Exit interviews were conducted with fifty clients using the gynaecology clinics at health posts that were
initiated by the project. The questionnaire explored clients’ perceptions of providers’ communication
with them. All clients interviewed for the study said that doctors listened to them while they talked
about their problems. ‘Asking questions in response to what the respondent has said’, ‘maintaining eye
contact’, ‘giving undivided attention to clients’ were reported as indicators of ‘paying attention’ to the
client. 15 women reported that doctors asked pertinent questions, six said that doctors maintained eye
contact with them, seven thought that doctors listened to them attentively when they were speaking
and eight thought that they got attention from the doctors because the doctors wrote down all of their
complaints. None of the fifty women interviewed for the study reported feeling shy to discuss their health
conditions.
Giving information to clients about diagnosis, treatment, investigations etc. is another indicator of good
communication. In the end evaluation 14 out of 50 clients reported being given information about treatment.
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Exit interviews of clients using services at the gynaecology out patient clinic at V.
N. Desai Hospital (2003)
Survey in 2003 covered 256 and 205 clients availing services from gynaecology outpatient clinics at
VNDH and MWDH respectively. Comparison of key findings with those from baseline / pre-intervention
survey showed uneven trend. Proportion of respondents reporting rude behaviour by doctor/nurse/attendant
decreased for VNDH and increased or remained unchanged for MWDH. Proportion of respondents not
informed about how and for how many days medicines needed to be taken and why certain investigations
were needed showed a decrease for VND and remained unchanged at MWDH. Proportion of respondents
reporting waiting time of less than five minutes on examination table increased for VNDH. Interventions by
the project for modification of layout and regular feedback to providers on communication styles have
been contributing factors for these positive changes. (Table 1 Annexure 4)
Counselling centre at gynaecology out patient clinic of V. N. Desai Hospital
Lack of counselling services was one of the factors identified by the participants of first QA workshop.
Women participants from the PID study also had pointed out need for counselling services for couples
seeking services for infertility, reproductive tract infections and contraceptives. Counselling interventions
by the project were linked to the interventions for improving client-provider communication. Provision of
quality counselling services was seen as an essential factor in quality communication between clients
and providers and as an essential component of quality reproductive health services.
Pre intervention (1997)
In the first QA workshop poor client-provider communication was identified as one of the factors resulting
in poor less than desirable quality of municipal health care delivery services. In this workshop the
participants identified problems related to the communication style affecting the quality of services. These
problems included lack of time to talk to the clients, no counselling services, improper information services
and at times language barrier between the health care providers and clients. The participants of the
workshop recommended better client information and counselling services as a part of providing good
quality health care.
In 1999 observations of client-provider communication in gynaecology out patient clinic of V. N. Desai
Hospital revealed that information and counselling needs of clients were not met adequately in the public
health system. Higher proportion of clients per provider, and lack of space and hence privacy for counselling
within the OPD as well as insensitive attitude of some of the providers towards clients were among the
most important factors contributing to the situation. In addition the providers needed to repeatedly answer
common queries a number of times a day. Lack of clarity about the role of nurses in the OPD and poor
communication between doctors and the other cadres further complicated the situation.
Interventions by WCHP
Discussion with users and providers at the hospital reflected the need for counselling services to be
provided by trained health care providers in addition to doctors at the OPD. WCHP responded to the
issues brought forth through the baseline studies by (1) modifying the layout of the OPD, and (2) establishing
a counselling and information centre within the gynaecology OPD, (3) efforts for improving coordination
and communication between the team members at gynaecology OPD.
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Box 5.2: Issues identified through analysis of 50 episodes of client-provider
communication
Disrespect (17)
•
disrespectful behaviour towards client
•
disrespectful comments about clients’ clinical condition
•
disrespectful behaviour towards accompanying person
•
exclusion of client who is capable of understanding and interested in knowing, from explanation
11
3
1
2
about impending surgery
Insensitivity (8)
•
non sympathetic behaviour towards client
•
insensitivity towards clients’ clinical and social problems
2
6
Inconvenience / discomfort to client (9)
• client sent back without treatment because of factors beyond the control of doctors 2
•
no place to sit for the client
•
long waiting time on examination table
•
seriousness of condition misjudged
2
3
2
Unmet counselling needs of clients and their spouses and /or family members
•
no support from family members to women seeking contraception
•
sex selective abortion
•
misconceptions about sex of the child
•
conception
•
care during pregnancy
(5)
1
1
1
1
Unmet information needs
1
(5)
•
client expressed need for more information
•
client not given choice of contraception
4
1
No space for men to discuss their reproductive problems
Benefits of having another person to explain
(1)
(1)
Modifications in the layout of the OPD
Original layout of the OPD — two rooms connected by a narrow passage — allowed use of only half of the
available space for most of the functions in the OPD. Of the two rooms available for the OPD, one was
used for stitches removal and by honorary doctors to examine cases referred to them by resident medical
doctors which together accounted for around ten percent of total utilisation of OPD. The other room had
two examination tables, two tables for resident medical officers (RMOs) and interns and a bench for
women to wait for their turn. Same door was used for entrance and exit and patient flow was frequently not
monitored. This resulted in crowding inside the OPD and around doctors’ tables and adversely affected
client provider communication.
WCHP appointed an architect to review and suggest layout to ensure optimum utilisation of available
space and to ensure pleasant work environment conducive for better client-provider communication. Passage
was widened and separate enclosures were developed for counselling centre and for honorary doctors.
Separate tables for intern and OPD nurse were introduced. This ensured easy access to nurse for
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assistance. Efforts were made to ensure linear flow of clients. Display boards were put up for appropriate
display of IEC material. A suggestion box was set up for clients and staff to put in suggestions / opinions
about their experiences.
Establishing counselling centre at gynaecology OPD
A training workshop on counselling skills was conducted for health care providers to sensitise them to the
principles and skills required for women-centred counselling. The counselling centre started functioning in
January 2002. Two ANMs from the project provide counselling services through this centre. Following the
training workshop on counselling skills ANMs and PHNs from H/E ward and from health posts with
gynaecology clinics who had participated in the workshop were placed at the counselling centre on a
rotation of 15 days each. They were supervised and guided by a trained psychologist appointed by the
project. This placement gave them practical experience in counselling for gynaecological conditions. For
a brief period MPWs from H/E ward who were trained in counselling skills by the project were also placed
at the counselling centre for a period of six months to counsel men accompanying women seeking
services at gynaecology OPD. Case records for each client counselled at the counselling centre are
meticulously maintained.
Guidelines were developed for counselling women and couples for conditions most commonly encountered
in the OPD such as willingness for and choice of contraceptive, MTP, major surgery, infertility, RTIS and
ANC. WCHP also developed a checklist to monitor the quality of counselling. The process of counselling
(communication between counsellor and the client) was observed with prior consent from client as well as
counsellor. Monitoring checklists were then analysed to assess the quality of counselling in terms of
clients’ rights ensured during the process and skills of the counsellor evident through the process. Issues
covered during the counselling session were compared against the checklists for counselling on that
particular issue.
Efforts for improving coordination and communication between the team members at
gynaecology OPD
Baseline showed lack of clarity about roles of para-medical and non-medical health care providers. WCHP
took initiative in organising meetings with the health care providers from gynaecology OPD to define
responsibilities of each member of the team. Realistic, practical job descriptions for each of the members
was developed and displayed on the display board as quick reminders to health care providers.
The project initiated bimonthly staff meetings to review the work and discuss specific issues including
problems/ difficulties faced by providers. Notes from the suggestion box are read out and discussed in
these meetings. Staff from labour ward and gynaecology and PNC wards, representatives from blood
bank, pathology laboratory, counsellors from voluntary counselling and testing centre for HIV/AIDS (VCTC
of MDACS) and representative/s of the hospital administration are also present for these meetings. Their
presence helps in problem solving and thus in improvement in quality of care. The proceedings of the
meetings are minuted and circulated to all those present for the meeting.
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Box 5.3: Feedback from suggestion box
”1 came on Thursday. Get good information here. Earlier it was not so. ” (“ Main Guruwar ko aai
thi. Yehanpar achha jaankari milti hai, pehle aisa nahi batate the”)”
I appreciate Dr.
ke bolne ka tarikaa achha laga”)”
’s way of communication. ” (“Dr.
Appointment for sonography should be given on the same day as of the ANC OPD “ “Can the
honorary doctors (bade doctor) come earlier?”
“Can we get Inferon injections free from the hospital? I cannot afford to buy them.
A reluctant woman who finally decided to opt for Cu-T after counselling had lot of pain during the
insertion. (Narration of her experiences by a woman.)
"If a woman delivers in the OPD other patients get scared.
tl
End evaluation (2003)
End evaluation of the counselling and information centre is based on interviews with clients who had been
counselled, observations of counselling process to assess skills.of the counsellors, interviews with staff
at the gynaecology OPD to explore their perception about relevance and usefulness of counselling services
provided at the OPD and analysis of case records of women counselled between January to June 2003 to
identify reproductive rights ensured through the counselling process. This evaluation was carried out by
an external evaluator Box 5.4 presents details of the methodology for the end evaluation.
Box 5.4: Methods and sample for the end evaluation of the information and
counselling centre
Quality of counselling
• Observation of counselling session (12, across the rangeof conditions for which counselling
is accessed. These include MTP, contraception, ANC, infertility, hysterectomy, uterine prolapse)
•
Exit interviews with clients who had availed of counselling services (16, including 2 men and
14 women. 12 of these 16 were users and 4 were non-users of counselling services)
•
Interviews with providers at the gynaecology outpatient clinic at VNDH (29)
•
Review of tapes of counselling sessions (10)
•
Review of records of counselling sessions (since phase I)
•
Review of counsellors’ ‘peer review reports’ (5)
Perceived usefulness of the counselling and information centre
•
Individual interviews with health care providers at VNDH 17
•
Present Medical Superintendent (1)
•
Ex- Medical Superintendent (1)
•
Honorary gynaecologists (3)
•
Resident Medical Officers (4)
•
OPD nurses (2)
81
•
Labour ward nurse (1)
•
OPD attendants (2)
•
OPD sweepers (mehtarani) (2)
•
Counsellors (2)
| Women Centred Health Pro ject I Report of the Hnd Evaluation
Focus group discussion with trainee counsellors from health posts 10 (one trainee was also
interviewed separately)
-
Auxiliary Nurse Midwives (ANMs) (6)
-
Multipurpose workers (4)
Exit interviews of users of counselling services 16
-
Women (10)
-
Men (2)
Group interview with 4 women non-users of counselling services 1
Individual interviews with WCHP staff 3
-
Project Coordinator (1)
-
Project staff (2)
Details of the evaluation of information and counselling centre are available in 'Cousnelling Services
in a Gynaecology Clinic of a Municipal Hospital in Mumbai: Experiences of Women Centred
Health Project, 2004’.
Interviews with clients
Ten clients who had availed of counselling services were interviewed to find out whether they were satisfied
with the services and whether they thought that they had benefited from talking to the counselors. All
respondents believed that the role of the counselling centre was to provide them information and to clarify
any doubts they may have. The respondents expressed satisfaction about attitude of the counselors.
They felt that the counselors talked to them with respect, made them feel comfortable and ensured
confidentiality Respondents also reported that they felt free to pose questions and clarify their doubts.
They appreciated patience shown by the counselors and that they gave information even if the client did
not understand it the first time. Feedback from the suggestion box supports these findings.
Box 5.5: Users comments on usefulness of counselling services
The cousnellors are patient and clarify our doubts and give us information even if we ask repeatedly.
(All respondents interviewed for the end evaluation)
I got information about sex and sexuality, which I would not have got anywhere else. Some people
may think that this is not ‘right’ but information can only help us. (counselling for ANC)
I found it very useful. I spent over an hour asking them questions and clarifying my doubts. It was
so useful that I did not give much thought to my six months old child whom I had brought along.
(Counselling for MTP and contraception)
Two men who had availed of counselling services were also interviewed. They were poorly informed about
the availability of services and were not as satisfied as the women respondents.
Evaluation of counselling skills through observations
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The trainee counsellors were seen to give inaccurate information in two of the 12 cases observed. In one
case the medical terminology was misinterpreted by the counsellor and in another the client who suffered
from domestic violence and had come for MTP against her husband’s wishes was asked to get husband’s
or mother-in-law’s signature on papers for MTP.
The two full time counsellors were very sensitive in counselling and demonstrated a gender perspective
but some of the trainees required guidance and feedback.
Box 5.6: Excerpts from report of external evaluator
...With the consent of the client concerned, I observed one MTP client being counselled. Overall
the counselling was of very good quality. The counsellor asked the client about herself.
The client... felt that she was ‘too weak’ and therefore did not want to go through one more
pregnancy. She... had decided to undergo sterilisation after MTP. The counsellorthen asked her
whether she knew how MTP was done. The client did not. The counsellor used the model of the
uterus and reproductive tract and explained D&C procedure. She then asked the client to ask
any clarifications. The client wanted to know about the length of the procedure and the time it
took to recover from anaesthesia.
The counsellor then gave a detailed explanation of all contraceptive options available to the
woman. She talked about the condom and vasectomy as well. However the client said that she
had decided on female sterilisation. The client then asked the counsellor whether she would talk
to the client’s husband who was waiting outside the OPD. “A man does not understand what the
woman goes through” she said, and so she would like the counsellor to explain to her husband
the MTP and sterilisation procedures and the care she needed after these procedures.
The counsellor readily agreed. The counselling session for this client took more than half-anhour, and another half hour or so was spent with her husband. The client expressed satisfaction
with the information and counselling provided....
Interviews with staff at gynaecology OPD
Key persons related to smooth functioning of counselling and information centre were interviewed to
explore their opinions about usefulness of the counselling services, need for such services and feasibility
of replicability to other municipal hospitals. The interviews also explored key health care providers’ and
administrators’ suggestions for improving quality of care.
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Box 5.7: Topics covered during interviews with staff at gynaecology OPD and
key administrators at the hospital
•
Profile
•
Role in the health centre/ health post/ project.
•
Counselling services: Has it been useful? Perceived changes in quality of care if any.
•
Obstacles or problems faced, overcome / resolved.
•
Review and monitoring mechanisms in place. Effectiveness, frequency and participation.
•
Need for such services: why? Who can continue? Who should be involved, take responsibility, any sugg
estions regarding systems to mainstream such services or any changes required in the present process
•
Sustainability.
•
Replication: required criteria / possibilities. If not possible — reasons.
•
Limitations perceived by them in providing services. Possible ways of overcoming these
limitations. For example, accessibility, acceptability of counsellors.
•
Suggestions to improve quality of counselling. Should anything be different or be done differently
by MCGM / WCHP? Any changes in the process, for example, referrals, lack of referrals.
Reasons and alternatives.
Medical superintendent of the hospital, two honorary gynaecologists, four resident medical officers, one staff
nurse and four attendants were interviewed for end evaluation. Key findings from these interviews are presented here.
Views on modification of layout of the OPD
The modification of the layout by WCHP was found to be effective. The health care providers felt that
modified layout streamlined patient flow thus reducing discomfort for clients as well as providers, and
ensured more privacy than was possible to provide before the modifications.
•
Perceived usefulness of counselling and information centre
All health care providers except one RMO felt that the counselling centre has been useful as it provided
information to clients that doctors can not because of the case load. The counselling centre was appreciated
because information / counselling helps reduce fear and anxiety of clients advised surgeries, women are
given choice of contraceptives and some who would have refused to accept any method would chose one
most convenient for them. The MS believed that counselling services would result in more satisfied
clients, improved client-provider communication and therefore lesser complaints. One of the RMOs
commented “(by giving information to clients) they do half our job.”
The providers were divided over the role of ANMs and MPWs as counsellors. Two RMOs, one honorary
and the MS were skeptical about the ability of paramedical (ANMs and MPWs) staff to provide counselling.
Another honorary doctor however preferred to have paramedical staff trained in counselling skills than
trained psychologists/ social workers as they (paramedics) would be better able to see the doctors’
perspective and there would be fewer clashes because of ‘medical versus social’ perspectives of clinicians
and counsellors respectively. “ Social workers stress on social factors of health problems while ANMs/
MPWs usually stress / balance both social and medical factors.”
Attendant at the gynaecology OPD attributed change in her behaviour to presence of counsellors in the
OPD,
we used to be very rude earlier. We learned from them how to talk well to patients".
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Box 5.8: Health care providers’ understanding of ‘role of counselling centre’”
... Promote something and make it look like her choice.” Honorary gynaecologist.”
... To provide humane interaction that is lacking in the routine hospital set up.” Honorary
gynaecologist.
’’Objective of the counselling services is to convert (clients’ decisions from) MTP - Copper T to
MTP-TL” Registrar 1.
’’Counselling services are useful as they save doctors’ time. Especially useful to tell patients
about MTP - TL.” Registrar 2.
’’Counselling is useful to motivate uncooperative patients. Useful to inform patients about their
problems or also those patients who come often for no problems. ” Houseman 2
i
"Counselling is useful to remove fear and do away with myths. They (patients) can get accurate
information. Very useful for unmarried girls especially who are pregnant, They get information on
how to prevent getting pregnant in the future and harms of repeated MTPs. ” OPD attendant.
’’The counselling services should continue so that patients get necessary information. In its
absence we have to talk too much. Counselling saves our time. We don’t have to listen to the
‘badbad’ [mutterings/complaints] of the patient nor do we have to do it. We can just send them to
the counselors.” OPD nurse.
•
Mechanisms for monitoring quality of care: bimonthly review meetings
Meetings are held every two months with the objective of discussing difficult cases, associated problems,
and feedback through the suggestion boxBoth the honorary doctors found these meetings useful to
improve services and felt that they should be continued. One of the honorary doctors believed that the
review meetings would provide space for orienting every new batch of RMOs that comes in every six
months. Suggestion box was appreciated as notes put in the suggestions box gave an idea about what
clients thought.
RMOs were not sure about the usefulness of the review meetings. One registrar felt that they should be
discontinued as the quantum of change that followed was not sufficient and that the suggestion box did
not make any difference. Another registrar felt that the review meetings should be continued but “should
not become slanging /mud slinging matches at the expense of RMOs” where RMOs and junior doctors
are blamed for everything. This registrar also felt that the notes id the suggestion box were not written by
clients (but by counsellors themselves). One of the housesurgeons supported the views. Houseman 2
felt that RMOs were “always blamed and never understood.”She found the review meetings one sided
where the RMOs could not speak freely in front of their superiors. She would prefer if the counsellors
talked one to one so that the problems could be discussed and resolved. Houseman 1 strongly felt that
the review meetings should be continued as they would be useful for improving quality of services provided
by the OPD. She also saw review meetings as a way of bringing in discipline in the OPD.
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| Women Centred Health Project I Report of the End Evaluation
•
Whether the counselling centre should be continued
All members of the staff interviewed at the VNDH except one registrar were of the opinion that the
counselling centre should be continued even beyond the duration of the project. The MS however expressed
inability to ensure that the ANM / MPW counsellors would be placed at the hospital. She said the matter
could only be addressed by the Executive Health Officer of the Public Health Department. She suggested
that organisations such as Rotary and Lions Club could be approached to provide financial support and /
or volunteer counsellors. She also suggested that ‘housewives or retired persons could also be involved
after being adequately trained. One of the honorary doctors suggested that one person should be
permanently placed at the counselling centre to increase accountability.
All the persons interviewed were confident that such an initiative could be replicated in other hospitals and
would prove to be very useful.
WCHP experiences — Output as compared to input
Despite a clear recognition by the providers about need for improvement of communication and provision
of counselling services, the process of initiation of counselling and information centre at the gynaecology
outpatient clinic at VNDH was lengthy and intensive. Sustainability of the counselling centre beyond the
duration of the project and regular monitoring of quality of counselling services provided through this
centre are the key concerns of the project.
1007 women and 186 men counselled since the centre was initiated provide a testimony to the unmet
need for counselling services in a gynaecology outpatient clinic.
Table 5.1: Clients counselled at the counselling centre at VNDH
Women
Men
January to June 2002
108
12
July to December 2002
283
113
January to June 2003
246
46
July to December 2003
370
15
January to December 2004
832
Total
1839
Couples
216
186
216
Table 5.2: Reason for seeking counselling — Analysis of cases counselled between
July -December 2003
Reason for counselling__________
Number of women
MTP and Contraception counselling
170
94
Only contraception
Major surgery ( e.g. Hysterectomy)
42
20
Infertility
15
Other gynaecological problems (??)
32
Unwed mothers
5
Tuboplasty
1
ANC
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Manual on ‘women centred counselling’ is a ready to use resource book for developing counselling skills
of the health care providers. Use of this manual will also enable the health care providers to develop
gender and reproductive rights perspectives towards gynaecological conditions.
Box 5.9: Topics covered in the ‘women centred counselling manual’
I
•
What is ‘Women Centred Counselling’?
•
Counselling skills and principles
•
Communication skills and principles
•
Communication around sexuality issues
•
Counselling for adolescent girls’ health issues
•
Counselling for gender based violence
•
Counselling around gynaecological health issues
•
Technical information on MTP, contraception, hysterectomy and ANC
•
Documentation and recording
Bimonthly review meetings initiated by the project are a useful mechanism for improving quality of care
provided through the gynaecology outpatient clinic. Successful use of suggestion box for obtaining feedback
from clients as well as co-providers has demonstrated the possibility of involving clients in reviewing
quality of care. This is an achievement for a public sector health care facility. To ensure accountability to
the hospital, the project initiated a system of submitting bimonthly reports of utilisation to the hospital
administration. The administrators from the hospital are intimated of all the bimonthly meetings and
decisions taken in these meetings. These systems have been approved by the administrators at the
VNDH and the staff at gynaecology outpatient clinic, are cost effective and can be successfully replicated
in other health care facilities.
Analysis of case records for January to June 2003
Case records of 123 women counselled between January and June 2003 were analysed from reproductive
rights perspective to explore whether the counselling centre fulfilled the objective of provision of women
centred counselling services.
•
Conditions for which services were sought at gynaecology OPD
Findings from analysis of case records are presented in Table 5.3. Women seeking MTP with or without
I
contraception formed around two thirds (58%) of the total clients counseled at the centre. These women
were provided with information about anatomy of female body, conception, procedure for termination of
pregnancy, its effects on body, available contraceptives and their advantages and disadvantages. Women
were then encouraged to make an informed decision. Husbands of these women are also counselled with
prior consent from the client. Ensuring right to information and choice is one of the most important tasks
performed by the counselling centre.
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Table 5.3: Analysis of case records
Rights ensured through counselling
MTP
Contraception
ANC
Infertility
Total
n=71%
n=24%
n=11*
n=9*
n=123%
Right to information
53
24
11
9
79
Right to choice
50
12
50
Right to decision making
47
10
46
Right to shared responsibility with partner
30
8
8
5
41
Right to comfort
29
4
6
3
34
Right to discuss sexual issues
10
3
6
15
Note: * Percentages not calculated.
•
Outcome of Counselling for MTP cases (n=95)
Need for and effectiveness of counselling to women seeking MTP can be assessed from the fact that
39% women who were unwilling to accept any contraceptive prior to counselling reversed their decision
following the information provided to them by the counsellors. 18% women changed their decisions about
methods of contraception and about termination of pregnancies. Following the information on all available
methods of contraception, 16% women asserted their right to choice by selecting a contraceptive that
was different than what the doctors suggested.
Evaluation also found lacunae in the counselling services provided by the centre. It was observed that
complete information was not given in 21% of cases. In 14% of cases male partner was not involved when
he should have been. In 8% cases women’s opinions were not explored and in 5% of cases problems in
relationship were not explored.
Box 5.10: Suggestions /recommendations for improving the effective-ness of
the intervention by mainstreaming the counselling centre
•
The Medical Superintendent should be actively involved
•
All the services should be reviewed on completion of a year for feedback on necessary changes.
•
The hospital administration/clinician should also be involved in the project and meetings
•
Efforts should be made to show more appreciation to the ANMs / RMOs etc. for example by
providing them with certificates -validating their efforts/participation.
•
Review meetings can continue to be conducted by the assistant honoraries. Both of them
•
could take turns.
Such services should be started in other departments too. Counselling for men should be
open to men coming to other departments too and also for men coming to the hospital for non
•
RH problems. Right now most counselling is about the wife or woman with whom he has
come or for infertility.
The ORD staffs must involve the counselors more so that work can improve and it also
•
•
encourages increase in work.
The suggestions/opinions of counselors should be welcomed.
The counselor at the centre should be someone who can directly discuss problems with
•
•
RMOs/other doctors in the OPD.
Better communication between doctor and counselor is required
The OPD sister can be trained and provide counselling. But a separate sister should be
appointed for this because the same person cannot manage OPD and counselling.
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Discussion
Perceived satisfaction by the clients is an important indicator for evaluation of communication. Unlike in
the baseline studies clients interviewed both at the gynaecology clinics and at the counselling centre at
VNDH reported being treated with respect and being able to ask questions. This is a definite improvement
in the communication of providers and possibly change in attitude of the providers towards clients. Training
workshops by WCHP as well as other efforts in the MCGM such as the Integrated Skills Development
Training of Reproductive and Child Health Programme have resulted in it. Findings of the baseline and
endline survey conducted at the gynaecology out patient clinic at the VNDH are important from planning
future interventions. The findings indicate that work environment that includes the physical structure of the
workplace, team spirit, and clarity about roles of each member of the team is as important to improvement in
client-provider communication as providers’ attitude and sensitivity towards social aspects of reproductive health.
Box 5.11: Achievements of WCHP regarding improving
client - provider communication
•
A counselling centre was established at the gynaecology out-patient clinic of a secondary
general hospital. The centre provided good quality counseling based on gender and
reproductive rights perspective.
•
Checklists for assessing quality of counselling services were developed.
•
Counselling Protocols for various conditions were developed.
•
Manual on ‘women-centred counselling’ was developed by the project.
All except one RMO found the counselling centre useful. They felt that it benefited the clients by providing
them detailed information that lessened their fear and anxiety about contraception procedures and better
prepared them for pre and post operative care in case of major surgeries. The counselling services helped
doctors by reducing their burden of giving information to clients. Staff at the OPD would like the counselling
services to continue beyond the duration of the project as well as to be implemented in other hospitals.
The providers attributed streamlined patient flow, decreased congestion and increased privacy to the
layout modifications by WCHP. Clients interviewed for the end evaluation also expressed satisfaction
about the information they received at the counselling centre. The fact that spouses or family members
could be involved in discussions was also appreciated. Feedback of the providers and administrators from
the VNDH on counselling centre as well as the modification of physical layout indicates effectiveness of
these interventions.
Sustainability of the centre is still an uncertainty. However the suggestions of the providers from the
hospital will prove useful in mainstreaming the counselling centre and for improving the effectiveness of
the intervention.
Improving Referral System
This was one of the three areas affecting quality of care provided by the MCGM that was prioritised for
development of test intervention. Need for an effective referral system was reflected through the baseline
studies.
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Pre-intervention (1997)
Focus group discussions with men. and women from the community showed that health posts and
dispensaries were considered to be health centres for women and children only. They were perceived to
provide services for ‘family planning, immunisation and treatment for minor conditions’. For inpatient care
and emergencies people used secondary and tertiary municipal hospitals and for minor ailments, private
providers were preferred. In this case, the person would visit the secondary or tertiary hospital if symptoms
persisted or worsened or if were perceived to be ‘serious’. Data from the exit interviews showed that
waiting time per OPD contact was 2 hours and 30 minutes at secondary hospital, 45 minutes at dispensary
and 21 minutes at health post. Health care providers interviewed for the base line studies also identified
poor referral system as one of the factors affecting quality of care provided through the municipal health
care services. The Project therefore initiated work on development of a test intervention that would ensure
optimum use of the three tier health care system of the MCGM.
Interventions by WCHP
In the second quality assurance workshop a group was formed with health care providers from the project
wards and representatives of the WCHP team as members to develop an intervention to improve the
referral system for the project wards. This included
•
Development of a four part referral slip that would allow the referred clients to be treated with priority
on par with senior citizens or MCGM employees.
•
V. N. Desai Hospital in H/E ward (a secondary hospital with eight specialities) and Mahim Maternity
Home and Post Partum Centre in G/N wards were identified as referral centres.
•
The referral slip was piloted in three phases.
Table 5.4: Results from the pilot implementation of referral system in three phases
No. of facilities
Number of clients
Number of client registered
participating in exercise
referred
at the referral centre
Duration
Phase I
1 month
14— one ward
178
33%
Phase II
1 month
14— one ward
132
65%
Phase III
12 months
22— both wards
769
45%
Midterm evaluation (1999)
The pilot referral system was evaluated on the basis of data on referred clients and on opinions of health
care providers who had participated in the piloting of the test intervention. 30 health care providers
participated in the evaluation. Of the 30 respondents 19 commented on usefulness of the referral system.
Of these 13 found the referral system useful for various reasons. (Interview guide used with providers is
presented in T-7.2 Annexure 7)
17 of the 25 respondents who had used the referral slip felt that the format of the slip was appropriate. Ten
reported having had difficulties using the referral slip. Seven respondents had suggestions for improvements
in the slip. These included suggestions regarding changing the format of the referral slip to decrease the
time required for filling it up. Other suggestions were about use of coloured case paper for referred cases
and indicating reason for referral, for example, investigation only or for investigation and treatment etc. on
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the referral slip. It was also suggested that treatment given prior to referring the client should also be
recorded on the referral slip. Providers from the referring units expressed frustration over referred patients
not being given priority at the referral centre. Other difficulties included lack of feedback from referral
centres and from clients.
16 of the 23 clients believed that it is feasible to refer patients with chronic conditions in need for regular
follow up back to the referring units. Providers from the referring units felt that distance of referral centre
from residence, perceptions about staff attitude, familiarity with the facility and providers, played a key
role in determining choice of referral centre.
Following the midterm evaluation the pilot intervention was discontinued. During the pilot phase it was
observed that, at times, the doctors from referring unit and the referral centre, disagreed on the need for
referral. This resulted in referred clients not receiving priority. Such instances also undermined the
confidence of the doctors from the referring units and challenged their credibility. This was considered to
be the major obstacle by the medical officers from the referring units. It was realised that unless this issue
was addressed, up-scaling of the exercise would not be successful. To overcome this problem the project
decided to develop referral protocols.
Development of referral protocols was a major task in itself and was not planned for in the initial project
plans. The project thus worked with a non-governmental organisation working on similar issues to address
this problem. A draft protocol for obstetrics and gynaecology was developed with a gynaecologist
representative of the partner NGO. The protocol has added value because the gynaecologist was an
employee of a municipal teaching hospital.
After the success of the pilot implementation of the referral system, the projectproject felt ready to share
its experiences with other municipal facilities. A slightly modified version of the referral system was
implemented in an administrative ward around one of the three teaching hospitals. However even this
model did not use detailed referral protocols and data was not monitored. The initiative was discontinued
after changes in staff positions.
Worried that the valuable experiences of project would go unheeded, the projectproject developed a
draft outline of a referral system that addresses the distribution of the primary, secondary and tertiary
health care facilities over a geographic area. For example, though ideally the referral chain would be
primary to secondary to tertiary facility, in the City zone of the metropolis, municipal health care
system consists only of primary and tertiary health care facilities and in the Extended Eastern Suburbs
it consists only of primary and secondary level services. Such distribution meant development of referral
protocols specific to each chain of referral units. The referral system proposed by the projectproject is
presented in Annexure 4.
The project therefore advocated for the development of referral protocols for all basic specialities seen at
the primary level - general medicine, paediatric medicine, gynaecology and obstetrics and general surgery.
The activity was later on adopted by SNEHA, The NGO that had offered assistance in development of
draft protocols for obstetrics and gynaecology, through one of its projects where WCHP coordinator is
one of the consultants.
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Discussion
Health care providers have repeatedly mentioned inadequate referral system as a factor affecting quality
of care provided by the municipal health care services. The responsibility of appropriate utilisation of three
tier health care services provided by the MCGM was placed on clients. A group of health care providers
involved in QA activities of the project believed that the use of a referral slip would be an effective way to
address the inadequacies in the referral system. This referral slip would also serve as a feedback mechanism
and orientation to health care providers from primary and secondary health care facilities. The results of
the pilot phases, however, showed that development of a referral model for Mumbai and even for municipal
health care services is an immensely complicated task and involved issues that can only be addressed
by senior administrators. The activity was found to be beyond the scope of WCHP and hence discontinued
after the pilot phases. The exercise however emphasised the importance and urgency of developing a
referral system for metropolis of Mumbai.
i
Box 5.12: Achievements of WCHP - Referral System
•
The project demonstrated the feasibility and usefulness of introducing a referral system in
MCGM.
•
The project documented the prerequisites and constraints for institutionalising the referral
system and developed a draft referral protocol for gynaecology and obstetrics in collaboration
with another NGO, SNEHA.
r
The pilot exercise confirmed that assigning priority on par with senior citizens or MCGM employees can
be an incentive for availing referral systems. Success of referral would also depend on awareness of all
the staff at the referral centre to the procedures related to referred clients. Inadequate orientation can lead
to clients not being given priority and hence being de-motivated for using the referral system. During the
pilot phases, lack of detailed referral guidelines led to referrals regarded as unnecessary by the referral
centre and resulted in demotivation of providers from referring centres. Lessons learned from the pilot
exercise will prove useful for further activities.
IL-
Box 5.13: Key issues emerging from implementation of pilot referral system
r
•
Inadequate referral system is an important factor affecting quality of health care provided by
municipal health care facilities. It also leads to less than optimum utilisation of three tier
health care infrastructure managed by the MCGM.
•
Results of pilot phases indicate that clients need to be given a choice of referral centre for
•
ensuring successful referrals.
Developing a model of functional and sustainable referral system is a complex task and
would involve development of referral links / chains, standard treatment and referral protocols
and administrative protocols. Political will is essential for success of such initiative.
1
?
i.
I
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Suggestions for mainstreaming ofreferral system
•
Primary health care facilities need to be strengthened in terms of physical as well as human resources
to enable optimum utilisation of the three tiered health care system.
•
Development of clinical, and administrative protocols is essential for successful implementation of
referral system. A referral system should have in-built mechanisms for feedback to referring units and
for referring clients back to referring units. Giving priority to referred clients is important and all staff
concerned with referral procedures should be well oriented with the procedures.
Drug monitoring
This was the third issue prioritised in the second quality assurance workshop for developing test intervention.
In the second quality assurance workshop a small group of health care providers worked on the issue of
non-availability of drugs to clients. Problems related to inadequacy of drugs were attributed to - (a) supply
level problems, (b) lack of proper distribution of drugs to the patients at the dispensaries and (c) misuse
of the drugs by the clients/ patients. Inappropriate distribution of drugs at facility level was considered to
be a significant problem. The group was of the opinion that pilferage or manipulation at the dispensaries,
dated or expired medicines and dispensing inadequate dosages were the main causes for non availability
(inappropriate distribution) of drugs to the patients.
During the workshop the participants were encouraged to identify issues that could be addressed at the
level of facilities and ward administration. Thus, supply-level problems and misuse of drugs by clients
were considered to be issues beyond the scope of the participants who were medical and paramedical
providers from health posts and dispensaries and administrators at the ward level. Lack of funds and
inappropriate indenting procedures were identified as probable causes for supply-level problems, which
need to be dealt with by the higher authorities of MCGM. Hence, the group felt that it was feasible to begin
with monitoring the drug supply to the patients i.e., pilferage at the dispensary level. The participants
designed an intervention to deal with pilferage if any at the facility level and non-availability of drugs to
clients due to human errors on behalf of the dispensing pharmacists.
This exercise aimed to develop a tool to monitor the problem of non-availability of drugs / inadequate
distribution of drugs to the patients at the dispensaries and to examine whether the tool developed was
effective for monitoring distribution of drugs to the patients.
The piloted intervention used a modified case paper (patient history sheet) for pharmacists to record
details of the medicines dispensed. The medical officer of the same facility was required to randomly
check whether the record matched with the actual quantity dispensed. In addition, medical officers from
neighbouring facilities were required to pay surprise visits (unplanned / non-scheduled visits) and check
the prescriptions for quantity of drugs dispensed. A checklist was prepared for compilation of the data.
First phase In the first phase, the exercise was carried out in two dispensaries in the G/N ward for a
period of four weeks, from April 2,1998. In one of the dispensaries, data was collected for 22 days and in
another dispensary for 24 days. Case papers for almost 6% of the patients seeking care during the study
period were scrutinised.
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An examination of 310 case papers (prescriptions) showed that 16 % of the patients were not provided
with the prescribed medicines. Most commonly cited reason (in 66% cases) for partial or total non
availability of prescribed medicines was ‘medicine not in stock’. Another 25% could not collect the medicine,
as they had ‘not brought bottle for collecting the syrups’.
Table 5.5: Outcome of Phase I of drugs monitoring exercise
Location
2 dispensaries in G/N
Duration of pilot exercise
22 and 24 days
Case papers checked
310 (6% of total)
Proportion of clients who received '
16%
prescribed medicines
medicine not in stock (66%)
Reason for non availability
not brought bottle for collecting the syrups (25%)
Second phase Phase II was carried out in G/N ward during July - August 1998 and in H/E ward during
November - December 1998. Three health posts from each ward that were adjacent to the dispensaries
were selected for carrying out the supervisory check i.e., to see how many patients are supplied with the
prescribed drugs.
In two of the three dispensaries from H/E ward and one dispensary from G/N ward all the patients for
whom the case papers were checked, had received all the prescribed medicines from the dispensary. The
third dispensary from H/E ward opted to drop out from the exercise. In G/N ward, 15% of cases medicines
were dispensed partially or were not dispensed. The reasons for non-availability of medicines were ‘patients
did not bring bottles for collecting syrups’ and ‘medicines not in stock’ (see table 5.7).
Table 5.6: Outcome of Phase II of drugs monitoring exercise
Monthly Patient
T urnover
Number of Case
Papers Checked
Number of Case papers on
which medicines was not given
PB
K
S
5850
2196
1944
139
136
142
6
60
nil
SVN
G
BN
2572
2063
3552
111
124
NA
nil
nil
NA
Dispensary
Health post
G/N ward
PB
K
MLC
H/E ward
SVN
PC
BN
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Table 5.7: Reasons for non availability of drugs - Phase II
Dispensary
Reasons
Number of
Dispensary
Reasons
case papers
case papers
^ila Bungalow Shortage of syrup
Drugs not in stock
[n=6)
Kumbharwada Sterilizer under repair
1
No syringes
(n=60)
2
No reason given
3
1
Bottles not brought
Dispensed quantity
differed from prescribed
Number of
by patients
1
1
35
Refrigerator not
working
3
Drugs not available
14
Drug supply not received
3
Other
1
Third phase A similar exercise carried out in the gynaecology department of the peripheral hospital
(table 5.8) revealed that ‘non availability of medicines on the MCGM schedule’ was the most prevalent
reason for patients not receiving the prescribed medicines from the hospital pharmacy (table 5.9).
Box 5.14: Methodology for dug monitoring study at the secondary hospital
•
Verbal consent from medical, paramedical and non-medical staff for observation of the prescriptions.
•
Consent from clients who were asked to report back to the ORD with medicines dispensed at the
•
OPD Pharmacy at the hospital.
Codes for recording non-availability of medicines at the hospital were developed and approval was
sought from the hospital administrators.
•
•
11 OPDs were observed and 148 prescriptions were monitored.
Prescriptions were written in duplicate. Clients were asked to collect medicines from OPD pharmacy
where the pharmacists recorded quantity dispensed and reasons for non-availability of prescribed
•
drugs.
Some of the clients were asked to come back to OPD with medicines. Quantity of drugs dispensed
was checked against prescriptions by doctors and representative of WCHP.
•
Data obtained from 148 prescriptions was coded and analysed using FoxPro and SPSS
•
List of drugs prescribed at the gynaecology OPD was discussed with RMOs to find out alternative
medicines that could be prescribed in the given condition. The same list was then discussed with
a gynaecologist from PPG to find out generic names / chemical components of the drugs prescribed
and whether these were on the drug schedules of the MCGM. List of medicines not on the
schedules was confirmed by the pharmacist from VND.
Number of OPDs monitored: 12
Number of prescriptions studied: 148
Total number of medicines for 148 prescriptions: 158
Total number of drugs prescribed for treatment of conditions presenting to OPD: 60
Drugs prescribed at the gynaecology OPD at the hospital which were on MCGM schedules and
were available to all patients: 42
Drugs prescribed at the gynaecology OPD at the hospital which were ‘not on MCGM schedules’
34/60
Conditions seen at the gynaecology OPD
Reproductive Tract Infections, Infertility
Menstrual Problems
------------------------------------ ------------------------------------- -------------------------------------------------------
L
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Table 5.8: Outcome of Phase III of drugs monitoring exercise: Drug monitoring
exercise at the secondary hospital
Results of drug monitoring
Number of prescriptionsn = 148
29
(20 %)
Some medicines or part quantity available at the hospital
32
(22 %)
None of the prescribed medicines available at the hospital
' 74
(50 %)
Information not available
13
( 9%)
All prescribed medicines available at the hospital pharmacy
(%)
Table 5.9: Reasons for non-availability of drugs at secondary hospital
n= 158*
Reason for non availability of drugs
Not on MCGM schedule
128
(81 %)
Funds not available
13
( 8 %)
Not supplied by manufacturer
10
( 6 %)
For MCGM employees only
3
( 2 %)
For inpatients only
2
( 1 %)
Bottle not available
1
( 1 %)
Note: * Actual number of medicines that were prescribed but were not available .at the hospital pharmacy
The drug monitoring exercise at the secondary hospital (phase III of the drugs monitoring exercise)
revealed that a little more than half (34 out of 60) the drugs prescribed for patients /clients seeking
services at gynaecology out-patient clinic were not available on MCGM schedule. These included antibiotics
such as norflox and terramycin, vaginal pessaries (used in treatment of reproductive tract infections),
antispasmodics, anti-inflammatory drugs, hormone based drugs, neuro-regulators and drugs used for
treatment of infertility. Most common reason for non-availability of drug was ‘Not on MCGM schedule’. List
of drugs that were prescribed but were non-available to clients during the course of study is presented in
Table 2 Annexure4.
The exercise showed that most of the reasons for non-availability of drugs were policy related and could
only be addressed at the level of senior administrators and policy makers. The exercise thus did not
succeed in improving drug supply to clients but it brought to light issues that are at the root of the non
availability of drugs at facility level.
Study of drugs indenting and procurement system at secondary hospital.
An exploratory study was carried out to study the ‘systems’ related factors responsible for non-availability
of drugs. Municipal procedures for' drugs indenting and procurement were documented to identify
bottlenecks. Study was conducted at a peripheral hospital for ease of access to relevant information.
Records for indenting and procurement procedures as well as the stock registers for the period of March
1998 - April 1999 were scrutinised for this purpose. Findings were later presented to MCGM authorities
responsible for the drug indenting and procurement system for MCGM peripheral hospitals by one of the
pharmacists of the hospital studied.
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Box 5.15: Factors that contribute to non-availability of drugs :
Pharmacists’ perspective
•
Lengthy administrative procedures and delays in completing them is the major problem
•
Difficulty in following up with suppliers as most of the suppliers (manufacturers / distributors)
•
were from outside Mumbai
Single supplier or common distributor for large number of drugs/items, thus problems with
one supplier or distributor affect supply of a large number of drugs/items.
Examples of procedural delays
• No response to quotations by the supplier / manufacturer. For a particular drug the quotations
were invited twice, no response was received.
•
The process of ‘placing indent -^Risk Purchase notice -> proposal for repeat purchase ->
sanction
I
placing an indent-delivery of the stocks’ takes a long time. In one case, stock
was received nine months after the initial indent was placed. Meanwhile for a period of three
•
months hospital reported NIL stocks.
Similarly the process of ‘placing indent -> Risk Purchase notice -> inviting quotations ->
placing an indent
delivery of the stocks’ is time consuming. For a vaccine (Inj.TT) stock
was received five months after the initial indent was placed.
i
Liaison with teaching hospital for training on Rational Drug Use and revision of drug schedules
In May 2001, the project liaised with a group of pharmacologists from a municipal teaching hospital
working on the issue of Rational Drug Use (RDU) and Essential Drugs List (EDL). Following formative
research in selected areas, the group of pharmacologists had brought out Standard Treatment Guidelines
for common conditions to ensure RDU and a booklet on EDL that was based on the World Health
Organization’s (WHO) recommendations. It was hoped that these would serve as guidelines for indenting
drugs at municipal facilities. The Project reviewed the drugs listed in the EDL with help from pharmacists
from the secondary hospital. Comparison with the Drugs Schedules of MCGM for May 2001 showed that,
of the 264 drugs listed in the EDL, 140 (53%) were not on the MCGM drug schedules. Of the 123 drugs
categorised in EDL as belonging to ‘U’ (universal) category, 50 (40.7%) were not on MCGM Schedule.
Table 5.10: A comparison of MCGM drugs schedules with Essential Drugs List *
Number (%)
Number of drugs listed in Essential Drugs List*
264
Number of drugs not available on MCGM schedule
140 (53%)
Number of drugs listed as ‘Universal’ (must have for all levels of health
123
care facilities) in Essential Drugs List*
Number of drugs listed as ‘Universal’ in Essential Drugs List* that were not on
50 (41%)
MCGM schedules
'Essential Drugs List: Universal and Speciality Outpatient Care, Municipal Corporation of Greater Mumbai,
WHO-lndia Essential Drugs Programme, July 1999.
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In keeping with its objective for improving quality of care, the project also offered assistance for organising
training programmes in Rational Drug Use for all medical officers from the Public Health Department.
Evaluation of technical skills of the medical officers at these training programmes largely showed satisfactory
level of knowledge regarding RDU. However this did not seem to be reflected in practice as revealed by the
r.
data collected by the RDU group. Discussion on this discrepancy repeatedly brought out the issue of a
large number of essential drugs not being on the schedule of MCGM.
With support of administrators from the Public Health Department and in collaboration with the RDU
group, the project initiated the procedure for setting up a drugs committee and ethics committee for the
Public Health Department. The proposed drugs committee was to review the schedules and recommend
additions or deletions from the schedules. Such revision would have provided the much-needed opportunity
for inclusion of drugs required for management of reproductive health conditions into the MCGM schedules.
>
However, sudden changes in leadership both in the Public Health Department and the RDU group resulted
in the discontinuation of these efforts.
Discussion
Non availability of drugs has been mentioned as one of the issues affecting quality of care by health care
providers. Addressing this issue is important for ensuring client as well as provider satisfaction. Exercises
carried out by WCHP identified some of the reasons for inadequate supply of drugs to clients. The
solutions to these lie outside the scope of the project and the health care providers at the health care
facilities. However the study also identified situations where discrepancies in prescription and dispensation
of medicines (tablets and capsules) was a result of human error. Mechanisms should be developed for
minimising such errors. Pre and post training exercises conducted for training in rational drug use showed
that theoretical knowledge of the providers was satisfactory from the aspect of rational drug use. The pre
intervention study conducted by the RDU group showed practice of irrational prescriptions by medical
officers from PHD. Discussion with participants of RDU training brought out the same points related to
non-availability of medicines affecting credibility of providers and therefore need to ‘give something from
what is available at the facility’. Non availability of some of the most commonly prescribed medicines for
gynaecological conditions is an important issue and needs urgent attention especially if range of reproductive
health services provided by primary health care facilities has to be expanded.
r
€
Box 5.16: Key issues emerging from the drugs availability study
•
e
Peer checks did not detect pilferage at the health posts and dispensaries. Obstacles/Problems
in indenting and procurement procedures play a significant role in ensuring adequate supply
of drugs to health care facilities. Mechanisms need to be developed for regular monitoring of
•
dispensing of drugs to clients.
MCGM drug schedules need to be reviewed and revised to include drugs required for treatment/
management of gynaecological conditions.
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Forming groups of health care providers and administrators to spearhead the efforts for
mainstreaming QA into the PHD
Till 1999, the project had focussed on health care providers from primary level health care facilities to
initiate changes leading to improvement in quality of care and a QA mechanism. In the fifth QA workshop
participant health care providers stressed that inadequate support from the senior and middle level
administrators affected efforts for implementing activities for introducing QA into the PHD. This prompted
the project to review its efforts for introducing QA into the PHD.
Issues emerging from the QA workshops and difficulties faced by the project in implementing QA
mechanisms in PHD, were discussed with a group of experts with experience of working on issues
related to quality of care with public health systems. Representatives of the PHD also participated in the
discussions. Participants of this meeting felt development of QA policy for MCGM and a Patients’ Charter
would be feasible strategies for implementing QA. It was decided to form two groups of representatives of
health care providers and administrators to spearhead QA activities in MCGM. The participants of the
brainstorming meeting believed that leadership / active involvement of such groups in developing QA
interventions would increase ownership of the MCGM towards QA activities.
Box 5.17: Composition and role of Working Group and Support GroupWorking
Group Members: One DEHO, Four AHOs, One WCHP representative
Role
• To review strategies for mainstreaming quality assurance, gender and management perspective
•
•
•
•
•
in the MCGM.
To facilitate decisions for mainstreaming quality assurance, gender and management
perspective in the MCGM.
To meet once a month to discuss the issues.
To present the issues in the monthly meeting of the DEHOs, AHOs and MOs.
To supervise and monitor the activities of support group in relation to patients’ charter, QA
policy, plans and implementation of the QA workshop, workshop for mainstreaming gender
and management skills.
To supervise and guide implementation of gender, QAand management activities in the MCGM.
Support Group
Members: MOsH.CDOs, MO i/cdispensary, FTMO,PHN,ANM,MPW,CHV and one WCHP representative
Role
• To develop plans, tools and methodologies for implementation of QAand gender activities in MCGM.
• To pretest the most feasible alternative at facility level.
• To present the proposed strategies to WG and take steps for implementation .
WCHP took on the role of providing support for the activities initiated by the WG and SG. Besides
documentation of the process in the form of minutes of routine arid special meetings, it was decided that
the project would offer assistance in terms of provision of reference material, monitoring of activities
following from the decisions made by the WG and timely feedback to the WG. The groups were dissolved,
after a period of one year as per the EHO’s orders.
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Box 5.18:Activities initiated by the Support Group and the Working Group
Support Group
•
Developed draft of Ranking System, presented in the sixth QA workshop
•
Piloted Cleanliness checklist developed in the fifth QA workshop
Working Group
•
Developed draft of Patients’ Charter of Rights and Responsibilities and presented in sixth QA
workshop
•
Organised sixth QA workshop
•
Organised a workshop for discussing issues around Convergence of Services at the level of
health posts and dispensaries
•
Visit to Thane site of World Bank funded Maharashtra State Health Systems Development
Project for a rapid review of referral system
Sensitising the public health system to patients’ rights
The Working Group undertook development of Patients’ Charter of Rights and Responsibilities as its first
activity: Existing Patients’ Charters and Citizens’ Charters were reviewed and a draft Patients’ Charter
suitable for MCGM was developed. Each of the points was thoroughly discussed in the meetings of WG
and SG. The groups agreed on most of the points. It was decided that the draft would be presented to the
Legal Department of the MCGM after obtaining feedback of all the MOsH, AHOs and DEHOs on it.
Minutes of meetings of WG and SG where PC was discussed are included in Annexure 4.
Box 5.19: Points of Patients’ Charter on which the WG could form consensus
•
Right to basic health care services irrespective of ability to pay
•
Information may be withheld from patients in cases where there is good reason to believe that this
might affect patients’ health adversely, however, information must be given to a responsible relative
(The Group would like to seek legal opinion on this issue.)
•
Right to refuse treatment to the extent permitted by law and be informed of the consequences
of the decision. (Define in QA Policy for MCGM Public Health Department)
(Term ‘as permitted by law needs to be defined. The Group would like to have legal opinion
for this point.)
•
Right to seek second opinion about his / her disease, treatment etc.
(For MCGM should the second opinion be from municipal teaching hospitals?)
•
All medications shall be labeled and include pharmacological name of the medicine
Administrators from the sixth QA workshop were asked to give feedback on the draft of Patients' Charter
and the Ranking System developed by the WG and SG.
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Box 5.20: Feedback on PC - Points from PC to which are not agreeable to one
or more health administrators
•
Right to health services free of corruption and political interference.
•
Right to basic health care, expensive life saving treatment and emergency services at hospitals
irrespective of ability to pay.
•
Right to need-based, situation specific outreach services as per the demand of the community.
•
Right to expect prompt treatment within the available resources in an emergency irrespective
of ability to pay, in the working hours of the primary and secondary health care facilities and
at all times in Casualty departments of secondary and tertiary hospitals.
•
Right to humane terminal care and to die in dignity (Feedback was received from seven
administrators)
Street play
On the occasion of International Women’s Day in 2000, the project presented a streetplay on Patients’
Rights and Responsibilities. This play was written by social work students from Nirmala Niketan College
of Social Work who were placed with Women Centred Health Project. The play was performed by the
street play group of the MCGM. The Project would like the Street Play group of the MCGM to include
performances of this street play in to their yearly routine.
Screening of feature film ‘Hari Bhari’
A special screening of Hindi feature film by Shyam Benegal presenting reproductive health problems of
women was organised for men and women from the community and for staff of the MCGM. 374 employees
attended the screening. Viewers included representatives from all cadres — from Deputy Executive Health
Officers to Community Health Volunteers and Peer Animators from the AIDS Cell.
A short questionnaire was given to the viewers before they entered the hall and were instructed to return
these after filling them after the movie. Of the 374 viewers 301 submitted completed questionnaires. All
the respondents reported having liked the film and acknowledged that issues presented in the film do
occur in real life.
Feedback from viewers from community as well as the health care providers (Table 4 Annexure 4) indicated
that they liked the movie as an audio-visual medium for presenting and discussing issues regarding
women’s health as well as reproductive health. Both the groups found the cases presented in the movie
to be realistic. The health workers could identify a number of issues emerging from the movie as issues
they could address to during their routine work (Table 5 Annexure 4). A large number of respondents from
the health workers as well as the viewers from the community identified social issues affecting the
reproductive health of the women (Table 6 and 7 Annexure 4). As suggested by the viewers from among
the community as well as the health workers the movie could be used as an aide for facilitating health
education sessions on reproductive health and on men’s role in reproductive health.
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Development of Ranking System
Ranking system (RS) was a tool for appreciative supervision. Development of RS was the first task
undertaken by the Support Group. The Ranking system considers health post or facility as a unit for
evaluation but at the same time it also takes into consideration the contributions of individual health care
providers. The RS is designed to evaluate aesthetics, personnel, availability of drugs and equipment,
patient satisfaction, utilisation of services and community participation and use of IEC techniques and
materials. Seven health administrators from the PHD gave feedback on RS. All of them believed it to be a
useful and feasible tool for appreciative evaluation. Additional criteria for performance appraisal suggested
by administrators are listed in Box 5.21. Discussion on RS in Support Group is presented in Annexure 4.
Box
5.21: Proposed criteria for performance appraisal
•
Inter Personal Communication
•
Utilisation of OPD at HP
•
Continuing Medical Education
•
Participation in national programmes at ward level
•
Performance vis-a-vis targets
•
Participation in competitions and results of these
•
Punctuality
•
Use of innovative ideas
•
Regularity/Attendance
•
Cleanliness
•
Budget utilisation
Pilot testing of tools I checklists for assessing quality
The support group discussed the cleanliness checklist (Tool 2) developed during the fifth QA workshop
and accepted the responsibility of piloting it in two facilities each from H/E, G/N and H/W wards. The
checklists were filled in by the staff at each of these facilities. In addition, a WCHP representative visited
all these facilities and used the checklist to assess the cleanliness. In G/N ward, Senior MO assesoed
cleanliness of the facilities using the checklist. The results were discussed with the SG. Practical difficulties
in implementation of checklists were discussed. The members of the SG were of the opinion that due
consideration should be given to factors affecting cleanliness of the facilities that are beyond the control
of the providers at the facility level. However, the group could not find a solution to these problems.
Box 5.22: Problems encountered in use of cleanliness checklist
•
No compound wall, surrounding community does not take responsibility for cleanliness
•
Roof too high, difficult to reach for cleaning purposes
.
Vacant position of health post attendant, attendant too old or unwell to perform certain tasks
ofcleaning.
•
Staff to clean toilets not available
•
Irregular supply of water
•
Covered garbage bins not available for all rooms
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Development of QA Policy
The WG believed that a well defined Quality Assurance Policy would set clear objectives and standards
for the health services. It would outline strategies to implement Quality Assurance at all levels.
Implementation of Quality Assurance Programme would encourage review of available resources and
reallocation of resources for maximum benefits, would ensure boosting morale of the staff, focus on job
satisfaction for the staff, increase motivation and thus lead to improvement in quality of care and
mechanisms for sustaining the standards of Quality. Continuous improvement in standards of care would
ensure client satisfaction and create a positive image of the MCGM facilities in the community. It was
believed that a QA policy would provide a broad framework for implementation of measures for improving
quality of care by ensuring appropriate utilisation of declining resources. The Quality Assurance Policy
would be a statement of commitment of the MCGM to the people availing health care services provided
through the MCGM health care facilities, for provision of‘Quality Health Care’.
Box 5.23: Proposed Quality Assurance Policy Objective
•
To bring uniformity in the efforts for improving quality of health care
•
To guide and streamline all further efforts for quality improvementlt would result in
•
increased satisfaction to clients and providers
•
optimum utilisation of available resources.
Adopting QA policy would ensure that
•
Health care services are oriented towards meeting needs and expectations of patients and comm
unity and are accessible the most needy needy in terms of physical, social and financial aspects.
•
Expertise of members (involved in the process of health care delivery) from different backgrounds
are optimally used by the health care delivery system.
•
Standardisation of care — development of protocols for treatment / management of cases,
prescriptions, referral etc. is implemented.
•
Mechanisms to ensure technical quality such as orientation and refresher training programmes
— are implemented and monitored.
•
Standards or indicators are developed for each of the activities undertaken by the health care
facilities.
•
Data is collected and analysed to assess the health care delivery system against the set
standards as one of the most important steps of the Quality Assurance cycle. A monitoring
system should be developed for regular assessment of the facilities.
•
Patients’ rights are respected by the health care system and that efforts are made towards
making them aware of their rights and responsibilities. .
•
Guidelines are set for coordination with other departments in the MCGM, for example
maintenance department, water supply, conservancy etc.
•
Mechanism of reward and punishments to build staff moral, team spirit are introduced in the
system and implemented.
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The outline of the QA policy proposed by the Working Group (presented in Annexure 4) was presented at
the sixth QA workshop did not receive any response form the other administrators present for the workshops.
The efforts then were discontinued when the WG was dissolved.
Discussion
Formation of groups to spearhead efforts for mainstreaming QA in PHD was appreciated by the health
care providers and administrators associated with the project. The groups however, were short lived and
did not result in complete transfer of ownership of QA efforts from the project to the PHD. In their interviews
for the end evaluation, the administrators expressed that the groups were formed ‘too late in the life of the
project’. By this point the identity of the activities initiated by WCHP as ‘pilot project activities’ was
impressed firmly on people’s minds. Change of leadership of the PHD at the crucial time contributed to
the abrupt discontinuation of activities for mainstreaming QA in the PHD through key health care providers
and administrators.
Box 5.24: Excerpts from the report of external evaluator
...WCHP’s efforts to mainstream quality assurance within the MCGM’s health services have
been among the first in this area to reach a wide range of health providers. ...Awareness-raising
and skill development have indeed been achieved.
A significant number of tools and processes for quality assurance and monitoring have been
developed by WCHP though an elaborate process of consultation with all stakeholders. These
tools are valuable and may be fine-tuned and disseminated more widely. Workshop modules on
quality-assurance training could probably be developed based on the workshops conducted by
WCHP, and field tested in other settings....
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Chafer 6
Implementation of Women Friendly And Client Friedly IEC
Objective 3
To implement women friendly and client friendly IEC by
•
creating links between the IEC Cell of the MCGM and the project
•
developing material with participation of clients
•
training of staff using these
Following studies provided baseline information for assessment of objective 3
A study of health care providers’ perceptions and attitudes towards women’s health and
•
quality of care provided by the municipal health care facilities
•
Exit interviews of users of municipal health services
Operationalising ‘women friendly and client friendly IEC’
The IEC component of the project became operational in 1998 when the IEC Officer was appointed. The
project took up development of gender sensitive interactive IEC material to address the unmet information
} needs documented by a number of baseline studies. Through out its duration the project focused on
capacity building of health care providers from the MCGM for sustainability of the initiative after the
duration of the project. This was done through establishment of IEC Core Committee for brainstorming
and providing guidance and leadership in the process of development of interactive material.
Parameters for evaluation
This objective was evaluated from the clients’ and providers’ perspective. Focus group discussions were
carried out with women who were given information using IEC material developed by the project. Recall at
the interval of three months and six months was documented. Good recall was considered to be an
indicator of 'good’ IEC material. Capacity building of health care providers in development and use of
client-friendly participatory IEC material was evaluated through interviews of providers and through reports
of training workshops.
Input indicators______________
• Numberof training workshops
•
Output indicators__________________________
• Number of health care providers trained in
organised for health care providers
development and use of participatory IEC material
Other workshops / training programmes •
Number of activities initiated by trained health
attended by members of IEC
care providers
Core Committee
•
Number of IEC material produced
Recall of clients
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Pre-intervention (1998)
A range of printed IEC material developed by the MCGM, provided by the State Government and that
developed by some NGOs was evaluated for client-centredness. Three posters, two booklets, two pamphlets
and one flip chart were reviewed using a checklist by team members of the project. The checklist was
used to assess the materials for sensitivity of the contents towards language, gender, literacy and culture.
Each of the print material was rated on the scale of 1 to 5 for the above mentioned criteria. For each type
of material, scores for each criteria were averaged to arrive at a general conclusion. Results of this
exercise are presented in Table 6.1.
*
Table 6.1: Review of printed IEC material using checklist
Strengths(score 4, 5 on the checklist)
Key message is clear
Contents are accurate
Appeal
Common people’s language used
Reflect cultural norms
Font size enough for even the neo
literate to read with ease
Quality of matter is good
Easy for health workers to carry and
demonstrate
Long lasting
Weaknesses(score 1,2 on the checklist)
•
Visuals not clear and are poorly
placed
•
Visuals culture, gender, age and
literacy insensitive
•
Style does not emphasise the key
message
•
Overall appearance not attractive
Booklet (3)
Convenient for the health workers to
carry and use in the community
Long life
Style emphasises key message
Visuals not clear and poorly placed
Visuals are culture and literacy
insensitive
Language is culture insensitive
Appearance unattractive
Handbill (2)
Message clear
Gender sensitive
Common peoples language used
Font size enough for the neo literate to
read
Culture insensitive language and
pictures
Flip charts (1)
Font size big enough for even the neo
literate to read
Convenient for health workers to carry
and use in the community
Long lasting
Visuals are not clear and not placed
appropriately
Visuals are gender age and literacy
insensitive
Language lacks culture sensitivity
Type of material
Poster (3 )
Review of the posters, handbills, booklets and flip charts using the check list showed that the pictures did
not convey the desired message and except for handbills were not appropriately placed. All four types of
print material reviewed were found to be gender, age, culture and literacy insensitive. And the overall
appearance of the material was found to be unattractive. In general it was felt that the reviewed material
was useful in training the health workers for conveying the messages but was of little use when distributed
directly in the community.
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The same material was also shown to women from community and their opinions about the material were
recorded. Review of this print material by women from community revealed that the signs and symbols
used in the material were not understood by the neoliterate women from the community. When multiple
pictures were used to convey a message, women failed to understand the linkages between them, and
hence to interpret the message correctly.
During focus group discussions, men and women from the community said that they preferred interactive
mode of health information where they could talk to the health information provider and clarify their doubts.
They also wanted the information to be on topics of their concern. Table 1 Annexure 5.
Midterm evaluation (May 1999)
Ten of the 14 members of the IEC Core Committee (Table 2 Annexure 5) were interviewed for midterm
evaluation. Analysis of contents of these interviews showed that the-respondents had a limited understanding
of the objectives of IEC. To most of them the purpose of IEC activities is for ‘mass awareness (jaanajagruti)’.
In the given structure of the MCGM, the AHO and artists from the IEC Cell play the key role in development
of the material. The health care workers who are expected to use the material for health education at
community level are not included in the process of development of the material. Health care providers did
not seem to have an idea about possible role they could play in the process of development of client
friendly IEC material. The IEC Core Committee members expressed the need to change the existing
process of material development and suggested involvement of grass root level health worker and community
in the process. Most of them felt that there was a need for a IEC Core Committee and that it could serve
the purpose of providing a platform for establishing a dialogue between the IEC Cell and the health care
providers. The Committee could also play a role in supervising and monitoring IEC activities.
An informative wall-chart in Marathi on reproductive tract infections (Mahiticha Bagicha) was developed in
a workshop where health care providers and representatives from NGOs participated. In 2001 PHNs and
members of IEC Core Committee set up by the project were trained for conducting health education
sessions on RTIs/STIs using Mahiticha Bagicha. Following the training and practice sessions, trainees
were asked to organise and conduct a training session using Mahiticha Bagicha , which was observed by
a WCHP representative. Observations were recorded using a structured checklist. The data was later on
analysed to identify weaknesses and strengths of PHNs and the members of IEC Core Committee.
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Table 6.2: Salient observations for health information session using Mahiticha
Bagicha
IEC Core Committee
PHNs
Prepared well for the session.
Need to improve documentation
Introduction of participants not conducted
Introductions conducted satisfactorily
satisfactorily.
Importance of ice-breakers needs to be
Appropriate use of ice-breakers resulting in
emphasised
interesting session
Objectives of the session were explained to all
Objectives communicated satisfactorily to the group
except one groups
Rules of the session explained satisfactorily
Skills for encouraging group participants were
Skills for encouraging participants were satisfactory.
satisfactory
Would benefit from further training on probing skills.
Facilitators accepted / respected views of group
members
Sensitive towards participants of session
Sensitive towards participants of the sessions
Easy to understand and common words used
Need to develop skills for story telling
Stressed all key points
Some facilitators need further training to
Topic of safe sex explained well by most groups.
overcome inhibitions to discuss issues like safe
Non penetrative sex not discussed.
sex.
Further training needed to generate response
on Chakravuha (gender and social issues
related to RTIs)
Information on RTIs could be modified to have
Technical information on RTIs explained well,
more technical information
received good response.
Training required on group facilitation skills
Need inputs on group dynamics and group facilitation
Facilitator, supervisor and recorded waited back
and discussed the session. It is a good practice
and allows for peer feedback.
Note: — Information not available.
The table indicates that the I EC Core Committee members demonstrated better skills in the use of the
MB than the PHNs. However the PHNs were better in introducing the session, use of interactive, participatory
training skills, explaining sensitive topics. Core Committee members had been provided 42 days training
over the six years period in comparison to the PHNs who were provided three days of training (Table 3
Annexure 5). Both groups would need training in group dynamics and group facilitation.
End evaluation (2003)
The Mahiticha Bagicha was used in the ISDT of RCH to demonstrate use of interactive IEC material for
health education. During the RCH training, the sessions were conducted with groups of CHVs. Hence for
the end evaluation, group discussions were conducted with four groups of CHVs. Two of these groups had
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been given information about RTIs using MB three months before the FGDs and the other two had been
exposed to MB six months prior to FGDs. Objective of these group discussions was to find out how much
and what do the participants in an information session remember after a period of three and six months.
Box 6.2: Methodology for assessing effectiveness of Mahiticha Bagicha
•
All groups were trained by the same trainer.
•
Contents of MB were covered with pieces of papers except for titles of the stories.
•
Questions were asked to explore whether the group remembered the story or the key messages
from the story.
•
Responses of the group were scored for accuracy of content and for spontaneity of
responses(the premise being that better recall will result in spontaneous / Jesser probing).
•
Any questions asked by the group related to the MB were answered at the end of the session.
The findings showed that participants from both groups could remember the broad contents of the MB.
The groups that had participated three months back in a health education session using MB, could recall
70% of contents and those who were trained six months prior to FGDs could recall around 60% of
contents. None of the groups could remember all issues discussed in MB. Three of the four groups could
not recall messages related to safe sex, prevention of RTIs, symptoms of RTIs in men and male partner s
responsibility regarding RTIs. The remaining group could not recall women’s responsibility in case of
RTIs. This group was trained six months prior to the FGD and recollected 72% of messages given in the
training session. For three groups included in the sample, training by WCHP using MB was the only
training they received on RTIs. The fourth group was a part of a project by Alert India (a NGO working in
the area of accessible health care) and continuously received inputs on various health issues. This group
scored higher than the other group for the recall of contents (62%).
Satisfactory recall of contents indicates the importance of use of interactive IEC material for health
education. Poor recall about symptoms of RTIs in men and male partner’s responsibility in case of RTIs
and inability of two groups to correctly explain ‘safe sex and non penetrative sex’ reflects need for more
inputs on related topics. Detailed findings are presented in Table 4 Annexure 5.
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Table 6.3 : Summary of findings of FGDs with CHVs for Assessing
Effectiveness of Mahiticha Bagicha
Number of questions in the guideline (maximum possible number of questions for a FGD): 33
Maximum possible score for accuracy of contents: 322
Maximum possible score for probes: 165
Natwar Nagar
Yari Road
Tata Compound
Kannamwar Nagar
asked
29
26
28________________
29
Topics / questions not
• Non
• Symptoms of
• Lessons / key
• Men’s
Number of questions
asked
penetrative
RTIs in men
sex
and women
messages from MB
• Women’s
responsibility in
• Prevention of • Safe sex
RTIs
• Points liked
• Prevention of
RTIs
about MB
Maximum
score
possible
for
responsibility in
case of RTIs
• Whether met any
case of RTIs
women with sym
• Whether met any
ptoms of RTIs
women with
• Points liked
symptoms of RTIs
30
99
40
about MB
29
292
223
282
293
206
157
170
182
71%
70%
60%
62%
145
130
140
145
144
126
132
98
omited
questions
Maximum
possible
score for each FGD
Score for contents
recall______________
Percentage of score for
content
maximum
recall
to
possible
score for each group
Maximum
possible
score for probes for
each FGD
Score for probes
Box 6. 3: Excerpts from evaluation report by external evaluator
.. .it is my impression that more materials could have been prepared during the project period that
could have been used effectively in the health posts, counselling centre and in the community.....I
feel that expending so much time on influencing the IEC Cell was one thing too many for the
project to have taken on in the area of systemic change, it is not clear how the investment made
in terms of enhancing the technical skills of IEC Core Committee members will be effectively
channeled in future...
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Discussion
Through a partnership of health care providers, members of the IEC Cell of MCGM and representatives of
community, the project demonstrated a process for development of interactive IEC material (box 6.4).
Sustainability or reproduction of the materials developed by WCHP (box 6.5) beyond the duration of the
project is uncertain. Inability of the IEC Cell of the MCGM to follow a meticulous process is an obstacle
in mainstreaming the lessons learnt through the process into the public health system.
Box 6.4: Protocol for developing gender sensitive, interactive IEC material
Steps involved in the development of gender-sensitive, interactive IEC material
Explore / determine the information needs of men and women of the community
Identify content required to meet expressed information needs
I
Develop illustrations pertaining to the information, making sure that they do not reinforce gender
stereotypes and unequal gender relations
Get feedback from men and women health workers from all cadres including doctors
I
Pre-test in the community
Modify based on feedback received
Check with doctor for technical accuracy before finalizing the content
Printing
Training to health care providers in use of IEC material
Box 6.5: Interactive IEC material developed by WCHP
•
Informative wall chart on- reproductive tract infections (Mahiticha Bagicha)
•
Pamphlets in Marathi and Hindi on reproductive tract infections
•
Pamphlets in Marathi and Hindi on ante natal care
•
Pamphlets in Marathi and Hindi on Medical Termination of Pregnancy (MTP)
I
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Because of various factors beyond the control of the project (vacancies at health posts, ad-hoc programmes,
poorly motivated staff), it was not possible for the project to carry out activities for creating awareness in
the community about their right to health care and information. The project’s activities also fell short in
reaching out to men in the community for providing them with information related to reproductive health,
reproductive tract infections and men’s role regarding these. There is a need for strengthening the capacity
building efforts within the MCGM for improving the quality of IEC activities and materials produced by
MCGM.
Box 6.6: Key Issues emerging from evaluation of initiative for implementation of
women friendly and client friendly IEC
•
Staff of the IEC Cell of the MCGM need to be sensitised towards the objectives of IEC and
role of health care providers in development of effective IEC material. The system of
development of printed IEC material for MCGM needs to be evaluated and modified to allow
for more active participation of health care providers and members of community in development
of interactive IEC material. Material thus developed will be far more effective in reaching the
message to people and contribute to awareness generation.
•
Qualifications of ANMs, MPWs and PHNs who are actively involved in health education
activities are varying . As a result the members of all cadres do not have adequate skills to
organise and conduct interactive group sessions. Sensitisation to concepts of IEC, workshops
for refreshing skills, active involvement in development of IEC material and regular monitoring
with constructive feedback will help in enhancing / developing skills of the health care providers
at primary level.
•
Recall for key messages from MB was found to be satisfactory three and six months after
the session, thus indicating effectiveness of interactive IEC material in reaching the messages.
Suggestions for mainstreaming participatory process of development and use
of IEC material
•
Considering the proportion / size of neoliterate population in Mumbai, various interactive approaches
for communicating information need to be explored. IEC material that primarily relies on written text
will prove to be ineffective in reaching the community. IEC activities should be planned to enable
discussion with the community after the demonstration of IEC material.
•
Health care providers as well as the staff of IEC Cell of the MCGM should be trained in use of
participatory methods for development of IEC material. Active involvement of health care providers
who are expected to use it at the community level is essential. Those associated with development of
IEC material should be trained in use of qualitative research methods to enable them to elicit feedback
from community which should be given due importance while developing the material.
•
The IEC Core Committee members are a resource with the Public Health Department whose skills
should be utilised to do periodic refresher training of the members at the IEC Cell and of the ANMs,
MPWs and PHNs.
L
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Chapter 7
Establishing Montoring And Evaluation Systems
Objective 4
To establish monitoring and evaluation systems by
• implementing supportive supervision system
• establishing systems for process evaluation of training, quality assurance, ability to meet
•
•
•
•
•
•
women’s information and support needs
establishing system for measuring effects of interventions on
health care providers’ attitudes and practices
users’ perceptions about quality of services
indicators of quality of care,
on indicators of effectiveness of services
measuring cost efficiency of all primary care services with special emphasis on selected
reproductive health services
Following study provided baseline information for assessment of objective 4
•
A study of health care providers’ perceptions and attitudes towards women’s health and
quality of care provided by the municipal health care facilities
Throughout its course the project developed tools for monitoring various interventions including the impact
of training workshops. Efficiency ofthese tools has been tested through regular use. Efforts were made to
involve health care providers and administrators from various levels in the development and testing of
tools. For monitoring of quality of clinical services the gynaecology clinics at health posts the project
involved gynaecologists from post partum centres.
Parameters for evaluation
Monitoring and supportive supervision systems were considered to be tools for ensuring QA mechanisms.
It was believed that a good monitoring system will recognise obstacles and empower health care providers
to overcome these and thus help in improving performance of the health care facility as a whole. This in
turn would result in increased provider and client satisfaction.
Box 7.1: Indicators for Objective 4 — Establishing monitoring and evaluation systems
Input Indicators
Output Indicators
•
Tools developed
•
•
Numberof supervisors using
monitoring checklists
Number of health care providers oriented in
use of these tools
»
Number of facilities with QA systems
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Interventions by WCHP
WCHP developed a number of checklists and tools for assessment and monitoring of various interventions
on regular basis.
Box 7.2: Monitoring Tools developed by WCHP
•
Checklist for monitoring client-provider communication
•
Self administered checklist for doctors for assessing communication skills
•
Checklist for assessing counselling skills of the counsellor
•
Checklist for monitoring quality of counselling for MTP, contraception and hysterectomy
•
Technical and administrative supervisory checklists for assessing quality of care provided by
primary level gynaecology out patient clinics
•
Checklist for assessing quality of interactive health education session
•
Checklist for assessing training skills of a trainer
•
Checklist for assessing client-friendliness of printed IEC material
•
Key questions to be used for exit interviews for assessing quality of client-provider
communication
•
Pre- and post- tests for each of the training workshops conducted by the project
•
Questionnaires for evaluation of training workshops (For details please refer to Paving the
Way: A Compilation of Tools for Mainstreaming Gender and Quality.)
Checklist for monitoring client-provider communication was used in the exercise conducted at a maternity
Home in 1998. This exhaustive checklist allows identification of aspects that need to be addressed for
improving the communication. A modified and shortened version of this checklist was developed for
doctors to use for analysing their own communication style. This self administered communication checklist
was tried out at gynaecology outpatient clinic at VNDH. Use of this checklist on regular basis (twice a
week) was introduced in March 2004.
Checklist for monitoring quality of gynaecology services provided through gynaecology clinics at health
posts and dispensaries were used by supervisors (MO PRC) since 2003.
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Findings of monitoring visits
Box 7.3: Findings of monitoring visits of Gynaecology Clinics at health posts
Technical supervisory checklist
Doctors in all the clinics did internal
•
Registers were maintained regularly.
examination
•
Registers were maintained by PHN or ANM
•
History taking was adequate
•
Chronic water problem affected two facilities
•
Doctors needed guidance in management
•
*
Administrative supervisory checklist
•
regularly
of chronic cases of white discharge
•
Equipments needed constant maintenance
Partner treatment was not adequate and
•
Regular drug supply was maintained
follow-up was lacking
•
There is a need for a system for speedy
redressal of staff problems
•
Appropriate referral was observed
•
There is no referral for investigations
•
For better utilisation of services regular
meetings with CHVs are needed
Box 7.4: Excerpts from report of external evaluator
...A significant number of tools and processes for quality assurance and monitoring have been
developed by WCHP through an elaborate process of consultation with all stakeholders. These
tools are valuable and may be fine-tuned and disseminated more widely....
Discussion
WCHP aimed at mainstreaming supportive supervision in the hierarchical set up of the PHD and at
developing of user friendly monitoring tools that can generate meaningful data, which is useful for planning
purposes. Assessment of components of health seeking processes such as client-provider communication
and counselling is essential for improving quality of care and client satisfaction. The tools have proved
useful for documenting key features of client-provider communication, quality of counselling, levels of
cleanliness and issues addressed during supervisory visits. These could prove valuable for routine monitoring
of health care facilities.
Box 7.5: Key Issues emerging from evaluation of efforts for establishing
monitoring and evaluation systems
•
Structured checklists ensure uniformity of data that is useful for evaluation and planning of
future activities and thus are tools for QA.
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Chapter 8
Capacity Building
Objective 5
Through all activities, build capacity of staff in two project wards and of the
"s
PHD of MCGM
Following studies provided baseline information for assessment of objective 5
•
A study of health care providers’ perceptions and attitudes towards women’s health and
quality of care provided by the municipal health care facilities
•
Exit interviews of users of municipal health services
•
Observations of client-provider communication at gynaecology outpatient clinic of a secondary
•
hospital
Identifying counselling needs of women seeking consultation at gynaecology outpatient clinic
at a secondary hospital
Operationalising ‘capacity building’
Expanding the range of reproductive health services and improving quality of care provided by the health
care services of the PHD have been concerns of the Women Centred Health Project. The project addressed
these by investing in capacity building of health care providers by sensitising them to the concepts of
gender, women-centredness, participatory approach in health care, clients’, providers’ and administrators’
perspectives of quality of care, quality assurance, development of interactive IEC material. Action research
studies carried out by WCHP were planned and conducted with active participation of health care providers
from project wards. Various committees formed by the project served as forums for discussion on various
topics. In addition to the activities organised by the project, select health care providers were sent for
workshops organised by other NGOs to provide them exposure and wider perspective on issues related to
implementation of client friendly gender sensitive reproductive health care.
Parameters for evaluation
Capacity building activities of the project can be grouped into (1) training workshops and (2) action
research. Training workshops were evaluated through pre- and post- tests and through workshop evaluation
forms filled by the participants. The evaluation assessed the effectiveness of training programmes in
sensitising the health care providers to concepts of gender, counselling, participatory IEC etc. and perceived
use of these inputs by health care providers. Interviews of health care providers associated with various
action research studies reflect changes in their knowledge and attitude. Relevant information from client
interviews helps us get an insight into the behaviour of the health care providers.
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Evaluation of training workshops is presented in this chapter. The training programmes by WCHP were
different than other training programmes conducted within the PHD for their use of participatory methodology
and introduction of providers for the first time to the concepts of gender, sexuality, counselling and
participatory IEC development. Key trainers were interviewed to explore their opinions and experiences
about the WCHP training programmes and interventions. This reflects changed attitude and increased
acceptance of project activities by the health care providers. Evaluation of contents explores the reach /
success of the training workshops in sensitising the providers to specific topics. (Tool used to interview
key trainers is presented as T-7.3 Annexure 7).
Box 8.1: Capacity building efforts
1. Four training programmes for key trainers to develop a group of resource persons capable of
conducting sessions on communication and counselling, and reproductive health
2.
One round training for clinicians to refresh the clinical skills in diagnosis and treatment of
select reproductive health conditions
3.
One round of training for ANMs and MPWs to build a gender perspective about women’s
health and role of health care providers and to provide technical information on select
reproductive health conditions (ante natal care, infertility, medical termination of pregnancy
and reproductive tract infections)
4.
Two rounds of training for CHVs for imparting technical and social information regarding
menstrual disorders and reproductive tract infections and orienting CHVs to their role in
treatment and prevention of these conditions
5. Project Coordinator, Training Coordinator and Training Officer from the WCHP were key trainers
for the Adolescent Girls Initiative - a reproductive and sexual health education programme for
non-school-going adolescent girls started by the Public Health Department of the MCGM.
6.
Two workshops for development of participatory IEC materials where participants were
sensitised to the development and use of gender sensitive IEC material
7.
One workshop for administrators from MCGM for Gender sensitisation
8.
Two workshops on participatory training techniques for RCH key trainers
9.
Training programmes for PHNs, in use of ‘Mahiticha Bagicha’, a wall chart on RTIs
10. Sessions on building social determinants and rights’ perspective on women’s health included
in the Integrated Skills Development Training of RCH programme
11. Sessions on gender, counselling skills, Quality Assurance, facilitation skills incorporated in
the ISDT of RCH for all cadres of health care providers
12. Four workshops on Gender and Health for MPWs
13. Three rounds of counselling training for PHNs, ANMs and MPWs
14. One workshop for doctors on skills for contraception counselling based on a rights’ perspective
15. Two rounds of training for laboratory technicians in performing investigations essential for
diagnosis of RTIs and those required in determining course of treatment for conditions such
as infertility
16. One training for key trainers- to select health care providers from primary level in Stepping
Stones methodology
17. Five workshops in Stepping Stones methodology to health care providers
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Interviews with key trainers
A study conducted between April 1997 and December 1997 to explore health care providers’ perceptions
i-A.
and attitudes towards women’s health and especially the social aspects of reproductive health conditions
formed the baseline for the capacity building component of the project. Information for baseline was
gathered through a questionnaire with open-ended questions. Medical, paramedical and non medical
health care providers from dispensaries, health posts, post partum centres, maternity home and secondary
hospital all managed by the PHD of MCGM, were included in the sample.
Mid term evaluation for capacity building component of the project was carried out in July 1999. Separate
questionnaires were administered for exploring health care providers’ understanding of gender, quality
assurance and to assess impact of various training workshops conducted by the project. All questionnaires
were open-ended. (T-7.4 Annexure 7)
End evaluation of capacity building component was based on interviews with trainees for various workshops.
Information was gathered through focus group discussions. To ensure absence of bias the discussions
were conducted by external investigators who had never interacted with the trainees before the meeting
but were familiar with the nature of the project’s work .
Inputs by the project were directed both towards capacity building of the staff in both technical and in
social aspects of health care provision that have a direct bearing on the quality of clinical services.
The Project followed participatory training methodology for all its training workshops. Training evaluation
forms for each of the workshops gathered feedback on training methods. This aspect of the WCHP
training workshops was also explored in midterm evaluation.
Midterm evaluation (1999)
The midterm evaluation aimed at reviewing the training programme conducted by the project in terms of
number of training programmes conducted, contents, methods used for training and the capacity of the
key trainers to conduct participatory training.
O'
A semi-structured questionnaire was administered to 30 trainees and 20 key trainers to evaluate the training
process. There were 13 ANMs, 12 MPWs and 5 PHNs in the group of 30 trainees. (T-7.5 Annexure 7)
28 of the 30 respondents reported liking the training workshops. The reasons given are — it provided
clinical knowledge on various health conditions of the women, the learning from the project would be
useful in the routine work of counselling women having infertility problems. Some have reported liking the
training for the informal atmosphere, conducive to learning that was prepared through use of games, skills
of the trainers in involving trainees in discussion. Sessions on gender, infertility and counselling were liked
because the participants (trainees) were introduced to the topic for the first time.
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Box 8.2: Feedback on training programmes organised by the project
“I have realised that men’s involvement in family planning is negligible and we need to take more
efforts to involve men. ” —
“I used to talk rudely with patients who lost their immunisation cards or did not come on their
appointed days. After the training I changed my way of talking so that women feel motivated to
come on the pre decided time for immunisation”— Male health worker
“.... circular sitting creates a feeling of oneness. It facilitates involvement in discussions.”
” The two way training method enable the trainees to find out solutions of questions emerging out
from their own discussions”
It was observed that the training changed the perspective of the trainees towards women’s problems and
some of the participants reported applying the knowledge gained from training in counselling for cases of
infertility and tuberculosis,
Box 8.3: Examples of application of skills acquired in WCHP training workshops
”A couple called me to the house and asked me why the wife has not conceived even after three years
of marriage. I could give them proper information and support”
“I counseled a couple and motivated the reluctant husband to go along with his wife for treatment
of infertility. The couple is now taking treatment in a private clinic.”
The opinion about the training methods used was mixed. Eleven of the 30 participants have appreciated
methods used in trainings and seven of these specifically mentioned participatory methods. Sixteen of
the 30 participants —11 ANMs, 4 MPWs and 1 PHN, expressed their dislike about the use of role plays
as training method . Eight of the 30 participants did not like the use of energisers, they thought these to
be ‘childish’ and ‘a waste of time’. Implications of this need to be considered while planning the training
programmes in future.
24 participants found all the topics covered in the training useful and 20 of the 30 had already applied the
knowledge and skills learnt at the training to field situations. However, the trainees expressed a feeling
that in absence of functional service delivery system the training has limited application.
Interviews were conducted with the key trainers to understand their opinions regarding usefulness of the
training and their experience about being key trainers. !6 of the 20 key trainers interviewed reported
‘feeling happy’ about being key trainers with the project. Nine of these 16 attributed this to the new skills
and knowledge they have gained through trainings. In response to questions in the semi structured
questionnaire, 10 of the 20 key trainers said that the training given by the WCHP helped them in their
work. Six admitted that the training helped them become ‘good listeners’, enhanced their ‘articulation
skills’ and ‘analytical abilities’.
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Four of the key trainers served as key trainers for other MCGM training programmes. All four found the
WCHP training different than the previous training in that, the previous training lacked participation of the
trainees and two way communication. Two of them appreciated the fact that in WCHP training, trainers
received immediate feedback from the trainees.
When asked to narrate a good experience of being a trainer, ten key trainers expressed satisfaction over
the fact that they could conduct participatory training. Overcoming the initial fear regarding cooperation
from peers was a very satisfying experience for them. Other responses are also associated with participatory
aspect of the training. The trainers expressed satisfaction over the fact that the trainees, after the inputs
from trainers could analyse issues clearly and present them as role plays or as slogans.
The key trainers also shared some difficulties. Most of the incidences were related to resistance from
participants of the training workshop to the participatory approach used by trainers. All key trainers who
had conducted the ANM / MPW training had negative experiences. However, none of the key trainers had
any negative experience regarding the CHV training. The reservation of the ANMs / MPWs towards
accepting one of the peers as trainers was probably responsible for the different reactions. Position of
CHVs in the hierarchy within the MCGM prevents them from questioning ANMs or MPWs who occupy
higher rung in the hierarchical ladder, thus making key trainers comfortable in the workshop situations.
Discomfort of the key trainers in addressing groups that question or can question their knowledge and
skills can be partly attributed to the lack of confidence of the key trainers. This also implies that the key
trainers defeated the purpose of participatory training methodology, which is to acknowledge trainees as
partners in the process of learning and ensuring
Another issue that might have influenced the experience of the key trainers is the dissatisfaction of some
MPWs and ANMs with the new tasks assigned to them, which they perceived as being outside their job
responsibility. WCHP training was seen as leading to additional new tasks assigned to the health care
workers and the protest against that affected the atmosphere in the trainings.
While discussing the ‘desired knowledge and attitude of the key trainers, most (11) of the respondents
expressed that ‘it is essential that the trainers have in-depth knowledge of the subject matter’. Understanding
the training needs of the trainees has also been pointed out as a ‘must have’ for the trainers. These key
trainers observed that ‘ for CHVs’ training use of common person’s language is necessary’.
Analysis of the data obtained from the interviews and the semi-structured questionnaires allows us to
believe that the key trainers have realised the need to bring about the change in attitude, skills and
behaviour of the providers. This is reinforced by the fact that the key trainers expressed a need for
following up the training to find out whether desired change has taken place.
End evaluation (2003)
A PHN from one of the project wards, a male gynaecologist who is a RCH key trainer and a male CDO
from the project wards who have been associated with the project through different activities were interviewed
for end evaluation.
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Box 8.4: Profile of the interviewees for end evaluation
PHN from one of the project wards has been associated with the project since 1996. She is
a key trainer trained by the project and has conducted CHV trainings on RTIs. She was
trained as SS key trainer and conducted the workshop for health care providers. She has
participated in three of the six QA workshops and was a member of the IEC Core Committee
and Support Group.
CDO from one project ward associated with the project since initial phases, is a key trainer
trained by the project, also a key trainer for SS. He conducted SS workshop for health care
providers. He was also a member of the IEC Core Committee, Men’s Involvement Committee
and Support Group.
Male gynaecologist, RCH key trainer, conducted ISDT for medical officers, ANM, MPW, PHNs.
Personal experience of associating with WCHP
•
Positive experiences
The MO and the PHN both reported change in perspective and personal growth as a result of association
with WCHP. The Project stimulated their thinking and has brought about changes in the way they
work. Both these respondents especially appreciated workshops organised by the project.
7 learnt to provide solutions to the patients’ problems from their perspective rather
than my own target oriented perspective and the staff who looks upto my practice
also has gone through attitudinal change. ’ RCH key trainer.
According to the PHN, Quality Assurance workshops led to increased thinking and reflection. After
attending the Gender and Health training organised by the project the ROH key trainer reported gaining a
new perspective on women’s health and becoming empathetic towards women and conscious of quality
of services.
The PHN finds her association with the project fruitful. It has given her an opportunity for personal growth
and improvement in her professional skills. She is convinced that the project is beneficial to the women
from the community and feels that in her ward a number of changes came due to WCHP.
The PHN and the CDO reported that earlier WCHP activities were considered to be extra work by the
staff. The PHN reported that as she became more familiar with the philosophy she was convinced that
the project would be beneficial for the community women.
•
Negative experiences as a result of association with WCHP
One of the interviewees had to face opposition from colleagues. They feared that if she continued doing
what the project told her to do, they too would have to do all those activities which, according to them was
extra work. She felt that even now some health care providers believed that WCHP activities were extra
work. Since she was convinced about the value of the WCHP activities, she ignored the remarks from her
colleagues and continued participating in the activities.
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Contribution of WCHP to PHD
Provision of women centred health services through gynaecology clinics at heath posts was considered
to be a big contribution of WCHP by the PHN and the CDO. They appreciated provision of services for
RTIs and STIs at health post level that was lacking in the earlier IPP-V project. Training programmes for
communication were appreciated by the PHN. She felt that at these training programmes she learnt “how
to reach people through communication". Introduction of Participatory Training methods was reported as
another major contribution of WCHP. The RCH key trainer felt that gender sensitisation within MCGM was
also the contribution of WCHP.
Activities initiated by WCHP that need to be continued
The CDO and PHN would like the gynaecology clinics at health posts to continue. The CDO felt that
counselling services need to be continued as all the staff has been trained and this training would benefit
the health care providers. The PHN would like communication training to continue. She would also like
the process of regular monitoring that the project followed to continue. Services for reproductive health
currently being provided through various programmes as AGI, FHAC, RCH should be brought under one
programme.
The RCH key trainer would like the gender training programmes to continue. He feels the efforts so far
have been “...just scraping the surface”. He too would like to see regular monitoring procedures in place.
The quality assurance component in terms of minimum standards needs to be institutionalised as well.
None of the respondents could specify the lessons that MCGM could learn from the WCHP experiences.
Suggestions formainstreaming
The PHN had very clear views on this. She felt that the senior administrators should know the project very
well, understand everything about project. At all levels in the MCGM —Bureaus, EPI etc. — the project
should be accepted, then the staff will also understand and accept it as their work.
Commenting on the slower than desired pace of the project activities, she said the municipalised staff
sees work as a burden. They do not ask themselves, ‘what can I contribute?’ This should not happen in
such future projects.
Sanctions for medicines, training should be periodic and ongoing to avoid procedural delays and
inconveniences to clients.
■»
Areas that need strengthening in PHD
Coordination between senior administrators in charge of various national programmes was mentioned as
an area that requires strengthening by the CDO and the PHN. They felt that lack of coordination at
planning level results in pressure on the grassroots workers who are responsible for implementing activities
for all the national programmes.
Another area mentioned by the PHN where MCGM needs to take action was resource shortages. Vacant
positions, inadequate stocks, equipment in non-working conditions all affect quality of care. There seems
to be no monitoring and appreciation of staff. The ANMs are forced to work but the MPWs have a very
dismissive attitude towards work and are never questioned by the administrators. This demoralised those
who put in sincere efforts.
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Evaluation of inputs through training workshops on specific topics
Gender
All training workshops conducted by the project had a gender component to them. The contents of the
training included conceptual inputs such as ‘gender and sex’, aspects of social norms/rules/customs’,
‘gender roles’, ‘rights and responsibilities ’, ‘access to and control over resources’, ‘power and decision
making’, ‘contribution of male and female sexuality and their relationship to health’ and ‘how different
diseases affect men and women differently’. In addition the participants were encouraged to apply these
concepts and do a gender analysis of (a) MCGM’s health department as an organisation and (b) the
health services provided by the MCGM.
A wide and innovative range of methodologies were used for the gender training. These included creation
of a story, analysis of case studies, small group discussions, sharing personal reflections, and so on. The
outcome of certain training sessions reflected rich analysis by the participants and helped build a body of
knowledge related to gender and health in MCGM.
Pre intervention (1997)
The baseline study conducted in 1997 revealed that health care providers did not often relate the social
factors in the women’s environment with their health conditions. Most common conditions with which
women present at the health care facility reported by providers from various health care facilities differed
by type of facility (Table 11 Annexure 1). The listing of issues reported as most common by health care
providers from different health care facilities can be considered as a proxy indicator of conditions seen at
these facilities. However ‘vaginal discharge’, ‘menstrual disorders’, ‘problems related to contraceptives’
and ‘other gynaecological conditions’ appeared among the first five most commonly reported conditions
mentioned by health care providers from all health care facilities. Inadequate grasp of concepts of gender
and its impact on health in general and especially on reproductive health is apparent in discussion on
‘factors that prevent women from being healthy’. While discussing reasons that prevent women from
being healthy, providers from all health care facilities mentioned ‘domestic problems’, ‘frequent child birth,
and ‘self neglect’. The suggestions for improvement of quality of care were about making drugs available,
ensuring adequate staff etc.
Midterm (1999)
28 of 30 ANMs, MPWs and PHNs who responded to a questionnaire developed to evaluate training
programmes by WCHP reported that they liked the training sessions on gender, infertility and counselling
because they were introduced to the topics for the first time. Analysis of data obtained through the
questionnaires showed that the training changed the perspective of trainees towards women’s problems.
Twenty out of 30 respondents reported knowledge gained from training in counselling for cases of infertility
and tuberculosis.
“A couple called me to their house and asked me why the wife has not conceived
even after three years ofmarriage. I could give them proper information and support”.
One of the MOH commented that he found gender training ‘very good’. It gave him insight into “...things
happening into our own family. This made us think of the gender issues’. One senior officer appreciated
the opportunity to do a gender analysis of the vertical programmes in the Senior Officers’ Sensitisation
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Workshop. This helped him to become aware of the problems of women TB patients and to make special
efforts to reach out to them. He reported that in the IEC material on TB, gender perspective was being
incorporated. In an interview during the midterm evaluation, a senior administrator expressed that she has
evolved with the project both as a person and as an officer and her own sensitivity to gender issues has
made her more empathetic. Due to her exposure to the project, she is now willing to think of special
services within the MCGM for women, like treatment and counselling of survivors of domestic violence.
End evaluation (August 2003)
Focus group discussions with eight ANMs, seven MPWs and interviews with two FTMOs and some
administrators were conducted to assess the providers’ perspective about reproductive health and the
efforts put in by the project in influencing attitudes and practices of the health care providers and as a
methodology for capacity building. In addition to the focus group discussions, three exercise were conducted
with the group of ANMs
• Word association : they were asked to associate the first thought that came to their minds in
response to a for key words like monsoons, Sachin Tendulkar, MCGM workers, gynaecology clinics.
•
Graded ranking of responses: participants of the group were asked to list the training programmes
they had attended and rank them using three words, ‘faltu’ (useless), ‘chalega’ (will do / ordinary /
OK), and ‘kaam me aya' (useful) and write down reasons for their responses.
•
Participants of the group were asked to write down case narratives depicting the link between
gender and reproductive health .
On being asked to identify the key aspects of the reproductive health of women who come to OPD, the
ANMs identified lack of hygiene,- socio-economic conditions, lack of attention towards health problems
and lack of health-seeking at onset of symptoms, illiteracy, low age at marriage, and too many pregnancies.
They wrote up short essays of women they had interacted with during the gynaecology OPDs connecting
these women patients’ gender and health experiences. Most stories reflected a functional understanding
of gender and health intersections.
The FTMOs who were interviewed had not undergone the gender training but demonstrated sensitivity to
women in their articulations of how gynaecological services could be improved.
MPWs who participated in the focus group discussion recalled a ‘very good’ workshop conducted by
resource persons from SAHYOG. The workshop on gender covered notions of equality, discrimination,
patriarchy, data and information on relative status of women in different countries and different states of
India, and role that MPWs can play towards gender equality.
The MPWs reported that training workshops taught them women are notweak. They also realised through
the training that men are circumscribed by traditional male roles. Men have the pressure to be masculine
‘they cannot cry or express their emotions because they would then be labeled “baayla" (effeminate).
They had also developed a gender sensitive perspective. Doctors have a medical opinion about pregnancy
and the possibility of sexual relations during pregnancy. But women’s feelings about this must be
acknowledged. It is not sufficient to go only by a clinical opinion.
The MPWs reported that trainings made them see how men and women are trapped by role prescriptions
(“Stree bhi peedit hai. Purush bhipeedit hai.
Women are affected by the system and men are affected
too.). The MPWs therefore felt that it was important for both women and men to perform their roles in a
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mutually supportive manner. The MPWs recalled the discussions in workshops about ideal husband and
men’s responsibilities towards women. MPWs also felt that women colleagues in MCGM did not
acknowledge that men have problems.
Key persons from the Public Health Department associated with the project for varying duration and in
different capacities were interviewed to explore their views about contribution of the project to the Public
Health Department. The interviews also tried to find out whether the interviewees (key persons) benefited
personally or professionally from interaction with WCHP. A male gynaecologist who is a RCH Key Trainer
reported gaining perspective on women’s health and becoming empathetic towards women and conscious
of quality of services. One senior administrator who had been associated with the project in the later
stage implied that the project had been unable to upscale the results and partly it was because of the
gender related agenda that the project was espousing, “in Mumbai and in MCGM no one would empathise
with the cause of gender equality.'’
Counselling
Pre-intervention
Out of the 70 health care providers interviewed for the baseline study, two ANMs and one CHV had stated
need for training in communication and counselling skills. In the first QA workshop rude behaviour of
providers was listed as an important factor affecting quality of care provided by the municipal services. A
small group of providers and WCHP representatives prioritised improvement in client-provider communication
as an issue that can be addressed by providers without additional resources.
Observation studies were conducted for documenting factors contributing to quality of client - provider
communication. Discussion with providers at the OPD brought out a need for separate counselling and
information centre managed by trained ANMs to address specific information and counselling needs of
women seeking services at the gynaecology OPD.
Interventions by WCHP
In August 2002 WCHP conducted counselling training for ANMs, PHNs and MPWs from two project
wards and initiated a counselling and information centre at the gynaecology outpatient clinic at VNDH. A
half-day workshop on contraception counselling was conducted for RMOs from gynaecology outpatient
clinic, and medical officers from health posts and dispensaries where the project has initiated gynaecology
clinics. Guidelines were developed for counselling women seeking services for contraceptives, MTP,
RTIs, childlessness and those scheduled to undergo major surgery. Health care providers trained in
counselling skills were placed at the counselling centre on rotation for a period of fifteen days to provide
them with practical experience. Trained counsellor appointed by the project supervised and guided these
health care providers. The providers were expected to provide counselling services to those seeking
services at health posts and dispensaries. Checklists were developed to assess quality of counselling.
End evaluation (July 2003)
Inputs by the project for provision of counselling services were evaluated by evaluating the counselling
centre initiated by the project in the gynaecology out patient clinic of V.N. Desai hospital. Among the
objectives of this evaluation were to assess the quality of counselling, to explore users’ and providers’
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perspectives about usefulness and effectiveness of counselling services. Data related to evaluation of
contents of training and gender and counselling perspectives is presented here. The evaluation process
covered 47 interviews of persons including providers, for feedback on counselling services. Interviews
were conducted by an external evaluator who was not directly involved with the counselling centre. One of
the points discussed was providers’ perspective on objective and purpose of the counselling services.
Seven of the fifteen providers interviewed for the study felt that purpose of the counselling centre was to
motivate clients for MTP-TL. One of the doctors said that the main objective was to ‘convert clients opting
for MTP and Cu T to MTP-TL. Counselling according to another doctor was also useful to promote something
and make it look like the clients’ choice.
Except for one doctor who was very negative about the counselling centre, all others found the centre very
useful because it reduced their workload. Before the centre was started, the doctors had to spend time
and effort explaining to the clients. Now the clients get explanations from the counselors. This allows the
doctors concentrate on other aspects of care. One of the attendant also agreed that since the centre
started functioning she is not required to listen to the clients and act as an interpreter in case the
providers did not understand the client. Such clients now can be sent to the counselling centre. Some of
the providers felt that the patients were better prepared for surgical procedures and better informed about
hospital procedures because of the guidance and information they received from the centre.
Stepping Stones Workshop
Stepping Stones (SS) is a participatory tool aimed at behaviour change for prevention and control of HIV/
AIDS. It is used as a training package on HIV/AIDS, gender, communication and relationship skills
designed for use in both, existing HIV/AIDS projects and general development projects that plan to
introduce an AIDS component. SS is designed to enable participants to explore issues affecting their
sexual health including gender role, money, alcohol use, traditions, attitude towards death, and aspects
of their own personalities.
Themes for the SS workshop include (1) Group cooperation, (2) HIV and safe sex, (3) Why do we behave
the way we do, (4) Ways in which we can change. Uniqueness of the SS lies in the fact that it does not
stop at giving information about HIV transmission and prevention, but also includes discussion related to
human and socio-cultural behaviour related to HIV and strategies to change this behaviour. Use of SS in
other part of the world (including other states in India) have reported changes in behaviour of participants
after the training workshop.
Box 8.5: Reported changes in behaviour of participants after SS training
•
Fewer quarrels among couples
•
Increase in condom use
•
Reduction in number of incidences of domestic violence
• Increase in mutual respect for each other among adolescents
(for details refer Implementing Stepping Stones Workshop in a Public Health Department, Experiences from Mumbai, 2004)
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Pre-intervention
Seven out of 70 health care providers interviewed for the baseline study had expressed need for further
training on AIDS. Providers involved in WCHP activities had at various times expressed need for further
inputs to deal with their inhibitions to discuss sexual and reproductive issues. This prompted the project
to organise SS workshops for select health care providers who could later on be trainers / facilitators and
conduct similar workshops in the community.
Intervention by WCHP
Training of Trainers (TOT)
In February 2002 a nine-days workshop was organised for health care providers and community development
officers from PHD of MCGM (13), representatives of WCHP (5) and representatives of other NGOs (12).
This training aimed to familiarise the participants to the concepts and methodology, train the participants
in skills required for facilitating SS, to share successful experiences in prevention, control and care in
HIV/AIDS/STD and to adapt SS to Mumbai context. First seven days of the workshop lead the participants
through SS as it is conducted for the community and on last two days the participants developed training
sessions, practices facilitation skills and received feedback from fellow participants.
Following the TOT administrative sanctions were obtained from appropriate authorities of the PHD and five
workshops were conducted to train all staff from eight health posts and dispensaries where WCHP had
initiated gynaecology clinics.
Training of Health Care Providers
Over a period of 15 months (March 2002 - June 2003), five SS workshops of six days each were conducted
by WCHP. Number of health care providers trained is presented in Table 8.1.
Table 8.1: Number of health care providers trained in SS
Categories of health care providers
___
Number
Community Development Officers
10
Public Health Nurses
13
Auxiliary Nurse Midwives
52
Multipurpose Workers
45
Full Time Medical Officers
6
Medical Officers in charge of dispensaries
3
Medical Officers from School Health Department of MCGM
4
Community Health Volunteers
13
Pre- and post- tests that had questions based on topics covered in the SS were administered to document
effectiveness of the training workshops, (for details refer ‘Implementing Stepping Stones Workshop in a
Public Health Department, Experiences from Mumbai, 2004’) . The tool aimed to elicit change in the
knowledge and perceptions of participants about HIV and safe sex, condom use, gender, communication,
attitudes towards sex and sexuality, love and sex, and interpersonal relationship skills. The tool also
included questions on health care providers’ role in addressing the concerns about HIV and STDs.
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Analysis of pre- and post- workshop tests showed increase in the scores for questions related to knowledge,
attitude and perceptions related to issues related to sexuality, safe sex practices, condom use,
communication and gender issues linked with HIV transmission and sexual health of men and women.
The change was more evident in the participants who had limited training in the past and were not
exposed to sexual health and gender issues in their work situation.
Box 8.6: Feedback by trainees of SS workshops
•
Lost our inhibitions, could express ourselves
•
Got to learn more about sexual and non-sexual relationship
•
Through this training learnt to speak about our reproductive health problems
•
Got complete, in-depth information about particular subject e.g. What women think about
sex (said by a male CDO) local terminology about sexual organs etc.
End evaluation (2003)
Four SS trainers were interviewed in May and June 2003. Of these two have been associated with WCHP
since its inception while two began their association with the SS Trainers’ Training in February 2002. One
focus group discussion was conducted with 17 health care providers who had participated in the SS
workshops conducted by the project.
Interviews with trainers
SS Trainers’ Training seems to have been a profound experience for the trainers interviewed for end
evaluation. It set off a process of introspection and reflection. One CDO said “I learnt that one should not
have double standards. There should be no gap between professed values and practical values. It taught
me to think. ‘Charity begins at home’meaning start from ourselves, improve our own thinking and behaviour.
Be models for community change. ”
Both the male CDOs interviewed expressed that the training had the effect of bringing about changes in
their relationships with their wives. Communication increased, as did their sensitivity to their partner’s
needs (including sexual needs) and they started giving them increased emotional support. ‘ I became
more sensitive to my family’s including children’s perception of me’
These.personal changes were reflected in their work as trainers. One CDO shared how he could speak
about his own dilemmas in the training and his own experiences of bringing about changes in his
relationships. These confidences helped to dissolve the fears and inhibitions of the trainers.
Another CDO said that her perception continued to change right from the Trainers’ Training in which she
was a participant, to when as a trainer, she heard the trainees reflections.
A male CDO stated that he became more client centred after the training in his work through the Asha
Cell (AIDS Cell of MCGM), that involved counselling hotel boys who visited CSWs. The value addition after
the SS training was that there was reduction in the defaulters who went back to CSWs. Another result
was that the hotel boys, a closed group, became more open.
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Results of the training were also positive as cited by the PHN. Three or four trainees telephoned her to ask
how they could replicate this process in the community. “They are demanding guidance now.n
All four trainers interviewed for end evaluation reported finding SS to be a profound experience. SS, one
trainer felt was not only a training programme but a tool for introspection that stimulated one to introspect
and find solutions for problems. Trainers also felt that SS methodology can be adapted to all community
health issues. Trainers found SS to be relevant not just for health care providers from primary level health
care facilities but for all senior policy makers and middle level administrators, and staff from all departments
of MCGM. Trainers believed that orienting administrators would create conducive environment for positive
changes in the public health system.
The trainers expressed concerns about the programme (SS for community) ‘being lost in the MCGM
unless it was taken overby an appropriate authority within the MCGM’.
Interviews with trainees
Trainees attributed openness in their relations with their spouses, improvement in counselling skills and
ability to discuss issues around sexuality with adolescents to the SS.
Participatory nature of the workshop was appreciated by participants. One of the participants felt that
beginning the workshop with confidentiality rules created a safe environment that encouraged participants
to share their expectations and feelings about sex and sexuality. Participants found SS to be an effective
methodology to reach information on issues related to gender, sex and sexuality to adolescent girls. A
CDO felt that SS provided him with thorough knowledge on HIV/AIDS and his communication skills have
improved.
Quality of Care - Quality Assurance
Pre intervention (1997)
Respondents for the providers’ study agreed that quality of health care services needs to be improved.
Most of them reported that training to staff was crucial for improvement in quality of care.
Table 8.1: Providers’ perceptions about quality of care in MCGM
Perceptions____________________________________________
Quality of care provided through municipal health care services is good.
Number
There is need for improving quality of health care provided by MCGM
63 (n=67)
It is possible to improve quality of care provided by MCGM
48 (n=69)
49 (n=69)
28 (n=68)
63 (n=69)
63 (n=69)
Clients will never be satisfied about quality of care
Staff is adequately trained to improve quality of care
Training is required to improve quality of care
Staff satisfaction is crucial for good quality care
51 (n=69)
Midterm evaluation (1999)
To find out whether the interventions introduced by the project as a part of the process of quality assurance
had any effect on the providers in terms of change in perception regarding women’s’ health, a questionnaire
was administered to 14 providers from both the project wards.
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All 14 respondents reported that through the activities of the project they acquired knowledge, which has
bearing on the quality of care. However these responses need to be regarded with caution, as they seem
to have a large component of courtesy bias.
Providers’ response to QA activities
A questionnaire was administered to those providers from both the project wards who had attended at
least one quality assurance workshop to find out the providers’ perspectives regarding quality of care. (T7.6, T-7.7, T-7.8 Annexure 7). Responding to the question asking them to define the criteria for quality of
care, the respondents covered many of the criteria for good quality of health care (table 2.5). They felt that
most of the criteria are absent in the MCGM health services. The reasons for absence or inadequacy of
the quality criteria and hence lower quality of care attributed mainly to lack of funds, shortage of staff,
shortage of drugs, etc. However, lack of or inadequate staff motivation, willingness, training, supervision,
monitoring, coordination, etc. did find mention as some of the reasons for absence of the criteria for good
quality health care.
Fourteen of the 18 respondents who attended atleast one of the five quality assurance workshops mentioned
that their ideas about quality of care have changed. Some of them have stated that they tried to implement
some quality assurance measures. The problems they faced while implementing the quality assurance
measures were the same as the reason for absence of quality i.e. lack of funds, shortage of staff, staff
resistance, shortage of drugs and lack of support from the superiors.
End evaluation (2003)
Interviews with ANMs, PHNs and FTMOs showed that when asked to identify factors that determine
quality of care this group assigned more weightage to availability of physical resources rather than skills
and attitude of the staff.
IEC
Pre-intervention (1998)
Evaluation of training workshops
The process of perspective building began with a workshop on ‘Concepts of health promotion for the
members of the IEC Core Committee members. 17 members participated in the workshop. Following this
workshop six other workshops were organised for the members of the core committee. Core committee
members were also encouraged to attend workshops organised by other NGOs. Details of these are
presented in Annexure 5.
Pre and post evaluation for the ‘Effective Communication’ workshop showed better understanding of
concepts of participatory IEC. Providers’ perceptions of objectives of IEC in the pre-test primarily focused
on ‘giving information to people’. In the post-test participants mentioned ‘involving people / clients in
development of IEC material’, ‘not only giving information but ensuring that the clients understood it’, ‘not
forcing out decisions on clients.but empowering them to make their own decisions’. In ‘essentials of
effective communication’ participants in post-test mentioned addressing peoples’ beliefs and
misconceptions, use of body language, maintaining eye contact, attentive listening, empathy towards
clients. The participants were not clear about the role of IEC Core Committee and its members before the
training workshops. In the post-test however the participants described the role of the Core Committee as
a forum for capacity building of the members. It would be the members’ responsibility to familiarise
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themselves to the principles of effective IEC and to develop their own skills. The members also identified
the potential of the committee as a forum for brainstorming strategies for effective IEC and reaching them
to the senior administrative officers. The participants were asked to give their opinion on the statement
‘people do not understand the information given to them’. Health care providers mentioned the necessity
of explaining in a way that the patients / clients can understand, use of examples and awareness that
people will grasp the information if it is relevant to them. In the posttest however they also mentioned
importance of exploring peoples’ problems and terminology and adapting the information to suit the
peoples’ needs. Post-training they also expressed that for people to understand the information it is
important that it is their need and that many times the providers do not ensure that the clients understand
information given by them. The fact that pre-test also shows large number of positive answers indicates
increased sensitivity of the providers to the clients’ needs. Increase in the number of positive points
mentioned in the post-test is encouraging and an indicator of acceptance of concepts discussed in the
workshops.
Perspective of providers about IEC processes and materials were not documented at the time of baseline
studies.
Midterm (May 1999)
Midterm evaluation for the IEC component was carried out in May 1999 i.e. one year after the initiation of
the efforts by the project. During this period the project had conducted one workshop on ‘Concepts of
Health Promotion’ for the members of the IEC Core Committee and two focus group discussions with men
and women from community. Evaluation of IEC efforts at this point was not useful in assessing trends or
direction that the efforts might take in future. For midterm evaluation, an open-ended questionnaire was
administered to ten of the 17 IEC Core Committee members.
Analysis of the qualitative responses showed that the respondents had a very limited notion of the objectives
of the IEC. To most of them the purpose of the IEC activities was only for ‘mass awareness (Janajagruti)’.
From the responses it was evident that the task of preparing material rested with the “artist’ and the senior
officers without any involvement of the health workers who are the actual users of the materials. Formative
research regarding perceptions of the people in the community who are the ultimate beneficiaries about
the material is not done. Also the pre-testing of materials produced is not carried out. The members of the
Core Committee have expressed the need for pre-testing the material.
Viewpoints of those involved in the FGDs regarding importance of community participation and understanding
people’s preferences for health information were different than those who had not been involved in the
FGDs. It seems that those who were involved in conducting the FGDs realised the importance of community
participation and media preferences of the people.
The members of the IEC Core committee had varied opinions about usefulness of the Committee. Nine of
them saw a role for the committee in the future. It was seen as a platform for voicing opinions (and offering
suggestions) regarding the IEC material used by the MCGM health services. Another opinion was that
‘the core committee should prepare client friendly IEC material through community participation’. Another
member found the meetings and discussions at the core committee meetings informative. One of the
members expressed the need for more technical inputs regarding the process of health education.
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Drawing from the experiences of the mid term evaluation, the project organised a series of workshops for
the members of the core committee for giving technical inputs regarding use of media like posters, film,
street play, flip chart and group discussion for IEC activities and preparing need based IEC material
involving community and the health workers. Also a number of FGDs were conducted with help of the core
committee members.
Discussion
Interviews with key trainers trained by WCHP for midterm evaluation showed that training of trainers
conducted by the project was effective in building the skills of the health care providers which proved
useful in their routine work at the community level. Trainees liked sessions on gender, infertility and
counselling as they were introduced to these topics for the first time during the perspective building
training workshops conducted by WCHP.
Health care providers interviewed for end evaluation reported to have benefited from their association with
WCHP in terms of skill building, and change of perspective. Gender training by WCHP was appreciated
by all interviewees. They suggested that it could be incorporated into other training programmes conducted
by the PHD.
Change from ‘poor understanding of links between social issues and women’s reproductive health as
reflected in the baseline studies to acknowledging that gender training “gave insights into happenings in
our own family" in midterm evaluation to a ‘functional understanding of gender and health intersection ’ in
end evaluation, speaks for the necessity of gender sensitisation for health care providers from all cadres
in the PHD.
In its initial years WCHP had difficulties in working with MPWs on issues related to gender sensitive
reproductive health and men’s role in it. On a number of occasions (informal as well as formal meetings)
the MPWs voiced skepticism about the usefulness of gender sensitisation training for men. At a point in
the course of the project, a small section of MPWs appeared to believe that the project was not only pro
women’ but it was anti-men. Following a few training workshops and participation in men’s involvement
committee formed by the project, during the course of interview for end evaluation, a MPW commented
that both men and women are trapped by traditional role prescriptions and hence it is important for both
men and women to perform their roles in a mutually supportive manner. This comment by a male
multipurpose worker, reflects some understanding of patriarchy and its effects on gender roles, and can
be considered a mile stone in the process of attaining gender sensitive health care services. The initiative
shown by MPWs for the development of a training module on reproductive and sexual health for out of the
school adolescent boys is an achievement in itself.
Stepping Stones workshops that address issues around gender, sex and sexuality and aspects of
participants’ personalities that could influence sex and sexuality was liked by all the participants. Trainees,
as well as the trainers interviewed for the end evaluation, believed that participation in SS should not be
restricted for health care providers from primary level. They would like to see SS incorporated in the
MCGM training agenda.
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Mainstreaming these training workshops in the MCGM have been attempted by WCHP. Efforts by the project
and all health care providers who participated in these programmes would go waste if this does not happen.
Absence of opportunities and continuing support to trainers would result in loss of trained human resources
Capacity building initiatives of the project have been useful in highlighting the untapped potential in the
public health department.
Box 8.7: Key outcomes of capacity building activities of the project
•
A pool of around 100 resource persons has been created within the Public Health Department.
This pool consists of 18 key. trainers, 13 RCH Trainers, 18 SS trainers and 39 MPWs and
CDOs who can work with men on issues of gender and sexual health.
•
WCHP has produced eight manuals which can be used by the resource persons.
•
Session outlines on Women’s Perspective, Gender, Counselling, Men’s Involvement and
Quality of Care have been incorporated into Mumbai’s ISDT for RCH and all health care
providers have been trained in these topics.
Suggestions for mainstreaming participatory training methodology
•
To ensure sustainability of the initiative, a team of trainers with representation from each cadre of
health care providers should be identified and given the responsibility of developing modules for various cadres.
•
A common training plan for various vertical programmes needs to be developed to build up a uniform
understanding of topics like gender sensitivity, social determinants of health, communication and
counselling skills. Training Cell of the MCGM should play the role of the nodal body in planning and
implementation of training programmes to avoid repetition.
•
The use of participatory training methodology should be mainstreamed in all MCGM training
•
programmes.
Stepping Stones workshop, intensive counselling training and workshops on gender and sexuality
should be included in the capacity building package for urban RCH.
Box 8.8: Excerpts from report of external evaluator
... capacity building activity especially in the area of gender, reproductive and sexual health
have made a deep impact on medical officers as well as on MPWs, ANMs and CHVs. The
foundation has been laid for building a rights-based approach to providing reproductive and
sexual health services through the communication and counselling training workshops....
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Chapter 9
Disseminaiton And Mainstraming
Objective 6
To disseminate and mainstream learnings from the project by
•
Creating structures within the project, committees and sub-committees
•
Relating with other programmes such as FHAC of MDACS
•
Up-scaling of selected interventions
Operationalising ‘dissemination and mainstreaming’
Women Centred Health Project came into existence with a clear understanding that the successful
experiments from the project would be introduced in to the larger MCGM system. To facilitate this, the
project has established coordination links with the MCGM through various committees (Box 9.1 ).
The Project adopted a participatory approach to facilitate mainstreaming of the learnings in the Public
Health Department (PHD) of MCGM. Issues for intervention were identified from discussions with health
care providers and they were also involved in development of the interventions. Suggestions of health care
providers were almost always incorporated. Various committees and sub-committees were formed to
provide for brain storming on various issues. The project hoped to provide an open environment free from
constraints of hierarchical structure where health care providers from community level could share their
ideas with officers concerned. Another objective behind forming committees was to develop leadership
within the PHD for continuing the initiative beyond the duration of the project.
Other efforts at mainstreaming included WCHP’s initiative and efforts for incorporating sessions on Women’s
Perspective, Gender, Counselling and Quality of Care into the Integrated Skill Development Training for
RCH in Mumbai. The revised sessions plan was presented in a meeting at the NIHFW. In the later stage
of the project, health care providers from wards other than H/E and G/N, who expressed interest were
involved in the project activities.
Informative wall chart on reproductive tract infections developed by the project was used in the ISDT of
RCH for training the providers to participatory methods of health communication. Thus all health care
providers have been trained in use of such material.
Whether learnings from the project are mainstreamed within the PHD or not is dependent on ownership of
the activities by the health care providers and administrators.
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Box 9.1: Committees and sub-committees established by the project
Steering Committee
•
Men’s Involvement Committee
Task Force
•
Module Preparation Committee
Clinical Sub-committee
•
MIS Advisory Committee
Reorganisation Committee
•
Support Group for QA
IEC Core Committee
•
Working Group for QA
Box 9.2: Indicators used for evaluation
Output indicators
•
Number of meetings by each of the committees
•
Number of participants for meetings
•
Number and nature of recommendations by these committees
•
Perceptions of members of the committees about usefulness of committees
•
Number of formats/tools/checklists/manuals produced by the project, being used in
municipal wards other than project wards
Midterm evaluation (1999)
At the time of midterm evaluation contributions of committees that were functional were reviewed. Members
of the committees were interviewed to find out their views about progress of the project towards achieving
its objectives, perceived reasons for not reaching the goals and their opinion about usefulness of the
project to the MCGM. Minutes of various meetings were reviewed to study views of various members on
issues discussed during these meetings.
Interviews with key members of various Committees
• Member of Task Force : Assistant Health Officer
While discussing the relevance of the project to the MCGM, Dr. B said that the project has helped the
MCGM re-focus and clarify the perspective on gender and women’s health. He further admitted having
benefited personally from the involvement with the project, “it has helped me understand other s feelings
not only as an administrator but also as a human being; resulting in making better judgments.”
He was positive about the impact of training on the health care providers. He felt that the workshops are
resulting in an indirect effect on the work culture. “I have noticed changes in the work atmosphere. We
have observed our own staff putting forth new strategies and taking initiative. A healthy competition is
developing.”
When asked for suggestions for promoting quality of care and gender sensitive health provision he said
that the project should take initiative for carrying out all the gender related activities, “ There should not be
duplication of activities and all gender related activities should go through WCHP only.... It should be
WCHP agenda.”
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He suggested that in the next two years one maternity home from each zone i.e. total of six maternity
homes should be strengthened to serve as central points for expansion. The project could also work at
the policy level to develop different modalities for the family planning programme.
•
Convenor of the continued medical education sessions (CMEs) and member of the clinical
subcommittee
Dr. G. was very critical of the progress of the project. While discussing the reasons for less than satisfactory
process he said that the fact that the project did not assess the workload and activities carried out by the
staff at the facility level before initiating new activities and ability of the staff to carry out additional
responsibilities, are responsible for slow progress. This is compounded by the fact that “The project lacks
authority to provide what the clinicians / providers ask for. Practical limitations they face are not paid
attention to. We are not providing solutions for their problems.” Dr. G voiced his concerns regarding
‘whether WCHP was proceeding towards achievement of its objectives’ saying “I am not sure whether the
end user would benefit from the project.”
According to him “addressing genuine grievances, presenting facts - stark picture to the DMC / MC along
with proposed solutions, addressing the inherent lethargy and the lacuna in the system” are the ways of
addressing the obstacles in the progress of the project.
However he expressed satisfaction about the progress of the CMEs in the G/N ward. The fact that the
CMEs are attended by 80% to 90% of the doctors from the G/N ward is a proof enough of the interest
shown by the doctors in the activity. He strongly felt that the CME programme is sustainable, “people
have inclination, one needs to give encouragement.”
•
Medical Officers of Health (MOsH) for the two project wards
The medical officers of health for the project wards played a key role in the planning and implementation
of the project activities. MOH for one of the wards was involved in the project activities since the inception
of the project. The other was in the project ward for the last two years (since 1998). At ward level the MOH
was the supervisor administrator of all the health posts, dispensaries and maternity homes.
Both the MOsH were of the opinion that the present approach towards supervision is of ‘supportive
nature’, in that the problems encountered by the staff are addressed to immediately by the MOH and his
office. However since the judiciary power of the MOH is very limited, they felt that the higher officers, of
grades of AHOs and DEHOs, would be able to address the problems more effectively. The grievances of
the staff are attended to in meetings. One of the MOsH felt that the workload is too much and affects the
quality of supervision.
Commenting on the training aspect of the WCHP one of the MOsH said that the training is “really good”
and participatory. “It facilitates the exchange of views among the trainees. Pooling together the suggestions
of the participants helps them to change their opinions.” Another MOH commented specifically on the
gender training conducted by the WCHP. He found gender training “very good”. It gave him an insight into
“...things happening in our own family. This made us think of the gender issues.”
When asked about the achievements of the project, both the MOsH mentioned ‘referral system’ as an
activity that has been effective. As one of the MOsH put it, “when the health post or dispensary doctor
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refers a patient and advises that she should go, it affects her mind, influences her husband and family
also. And she goes. Otherwise she would neglect her health.”
Following were the suggestions regarding activities that could be taken up by the WCHP in the next two
and half years -
•
Module for quality assurance should be prepared and given to the administrators for improving quality
of health services in Mumbai.
•
Training for CHVs should be continued.
•
CMEs help in refreshing the knowledge of the doctors. The project should work with the administrators
for mainstreaming these.
•
Difficulties in implementation of the above mentioned activities and gender should be presented to
the administrators and rules for mainstreaming of these should be formulated by them.
•
Project should work towards building partnership between the private voluntary organisation and the
MCGM health care system. The MCGM would like it.
End evaluation (2003)
Stakeholders from the PHD of MCGM were interviewed for the end evaluation. (T-7.9, Annexure 7) They
included Ex-EHO, two members of the Working Group for QA and AHO IEC. Their opinions about contribution
of the project and sustainability were explored.
Ex-EHO who supported the project through out her tenure felt that it has taken time for the non-MCGM
people in WCHP to understand the system and to some of them the system has also come as a culture
shock. Commenting on the success of the project in meeting its stated objectives, she said that for
partnerships to be successful, voluntary participation of people within the system is essential. While
skills can be developed, attitudes and the will to work are important pre-conditions. She also said that
after the project ends it is important for the trained people within the system to remember and use what
works with the community.
Dr. Thanekar (DEHO) was associated with the project as the convenor of the Working Group for QA. In his
opinion the project has not been able to make impact. He stated various reasons for this, the main being
delayed involvement of senior level officers into the decision making process. According to him, some
strategies were hasty and were implemented without giving a thought to what is feasible.
Dr. Kewalramani AHO (IEC) thought that the IEC Cell has benefited from the new ideas and perspectives
from the WCHP and these will help the staff who have undergone training.
Dr. Keskar AHO, member of the Working Group for QA felt that the involvement of senior level officers, not
only in terms of the project’s rapport with them, but in terms of functional ownership had not been there.
In her opinion the project has fallen short of getting the rest of the MCGM to accept that QA was relevant
to the entire public health department. (QA thus remained the “project’s baby”.) She felt that changes in
policies are required to carry forward the ideas and efforts of the WCHP and for this officials higher than
DEHOs will have to be involved.
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Discussion
Hierarchical set up of the PHD posed the greatest barrier in up scaling the learnings of the project. The
bottom up approach followed by the project that is meant to empower and motivate the individuals on
lower rungs of the hierarchical ladder proved to be of limited use in the set up of the PHD. Wide spread
perception among the administrators that senior officers from the PHD were not involved in the planning
and implementation of WCHP is the main reason for lack of ownership of the project by the PHD. Some
senior officers also felt that interventions for improving quality of care that would be beneficial to the
system were presented as suggestions of the project. It was felt that these outcomes would be more
readily accepted if they came as a decision of and instructions from the senior administrators.
Views expressed by various senior officers interviewed for midterm and end evaluation indicate that the
project succeeded in bringing about small or local changes such as initiation of gynaecology services and
counselling centre, but fell short in its efforts for changing attitudes of administrators from the PHD and in
creating ownership by the system.
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SECTION 3
SUMMARY OF END OF THE
PROJECT EVALUATION
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Chapter 10
Summary
Women Centred Health Project took upon itself the task of mainstreaming gender and rights perspective
in the PHD of MCGM. In 1996 there were very few projects in India that were attempting this. To create an
environment conducive for change the project began its activities from the staff of primary health care
facilities. Key strategy was capacity building of health care providers. The project conducted a number of
training workshops to sensitise the health care providers to the concepts of gender and reproductive
health as well as to develop skills required for provision of quality services. This strategy relied on change
in attitude of the participants towards women’s reproductive health to be the motivating factor for change.
Significant achievements of the project
•
Initiation of eight primary level gynaecology clinics providing quality basic reproductive
health services and referrals.
Through establishment of eight gynaecology clinics the project demonstrated feasibility of expanding the
range of reproductive health services at primary level. These clinics are a proof that much needed services
for RTIs and menstrual disorders can be provided at the community level at minimum extra cost to the
MCGM. The experiences of the project in initiating the clinics helped identify pre-requisites for provision of
basic reproductive health services at the primary level. This exercise also pointed out the importance of
regular monitoring in smooth functioning of health care services.
Key role of community health volunteers in reaching reproductive health services to community women is
another important fact that came out of this experience of establishing gynaecology clinics at primary
level. When trained in basic skills of communication and offered technical inputs relevant to reaching out
to women with reproductive health problems in the community, CHVs can encourage women for early help
seeking for RTIs.
•
Piloting of referral system which currently is being upscaled by SNEHA
The exercise of piloting a referral system for Public Health Department helped project identify the key
components for a quality referral system. The task was vast and of complex nature hence handed over to
an organisation committed to work on the issue. Data obtained from the pilot phases of the referral
implementation and process documentation of the experiences would help future efforts in MCGM regarding
improvements in referral system.
•
Initiation of a counselling centre in gynaecology out-patient department of V.N. Desai Hospital
Good quality counselling services are being provided by two ANMs from PHD. 1839 women, 186 men
and 216 couples have been counselled since initiation of the centre in January 2002. Counselling
services are appreciated by clients (users) as well as providers. There is a strong recommendation
that the counselling centre should be continued and replicated.
Lessons learnt that reorganisation of gynaecology out patient department in terms of physical layout,
patient flow, regular staff meetings and accountability measures such as installation of the suggestion
box, will result in improvement in client-provider communication.
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•
Drugs studies done by the project indicate that the MCGM drug schedules need to include medicines
on the Essential Drugs List and indenting and procurement procedures need to be streamlined to
ensure availability of drugs to patients.
•
QA tools such as the Patients’ Charter, facility ranking System, and Cleanliness Checklist have been
produced with consensus of stakeholders and have been pretested, they are ready for up-scaling.
•
Gender sensitive, client friendly IEC materials have been produced on MTP, ANC and RTIs. A
methodology for production of this kind of materials is established. Bulk production of the WCHP
produced material can be done by the IEC Cell of MCGM.
Major shortcomings of WCHP
•
Research in GO-NGO partnerships shows that success of a collaborative project depends on willingness
of the public health system to accept / keep an open mind to the suggestions of the project, whether
the resources of the NGO are seen to be fulfilling the system’s needs and at what level the NGO
positions its efforts — whether it seeks systemic reforms that could be threatening to some of the
stakeholders or whether it engages into non threatening tasks such as community mobilisation.
Women Centred Health Project attempted to mainstream concepts of gender and quality of reproductive
health care that are regarded as a low priority by the bureaucracy. Project activities were poorly
presented in the routine reviews by senior administrators and the department heads. Thus came the
lack of ownership among the health care administrators about the learnings of the project.
Since the project was located within the PHD of MCGM it had to follow the communication protocols
dictated by the PHD. This limited the communication between the NGO partner and the senior
administrators.
•
Various committees were formed as a step towards mainstreaming of learnings form WCHP into the
Public Health Department. Though, Clinical subcommittee, IEC Core Committee and Module Preparation
Committee contributed significantly to the activities of the project, other committees could not take
roots due to inadequate support from the senior administrators.
•
WCHP organised workshops to orient the staff of IEC Cell of the MCGM to participatory way of
developing IEC material. Most participants reported liking the training but the policies of the MCGM
need to change to allow application of the learnings of the workshops.
•
The ANMs in the PID project had been deputed full time to the project. In the case of the WCHP early
attempts to start the gynaecology OPDs were construed by a section of the health-providers as an
addition to their workloads. The project did not anticipate having to deal with unions.
•
The ANMs in the PID project became researchers whose new roles did not necessitate confronting
the system. In the case of WCHP, this was not true. At every stage the system had to be reckoned
with. Capacity building for health providers did not automatically make it possible for them to apply
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their learning to service delivery within a rigid system steeped in hierarchies. Health workers required
support from the system to make it possible for them to deliver services.
•
The WCHP focused much of its efforts in involving lower-level staff for bringing new inputs. Through
participatory processes, it attempted to acknowledge the health providers as legitimate stakeholders
of system change. However, for instituting change, the intervention of higher-ups was necessary. The
project did set up a working group towards this but much of the efforts from the participatory processes
did not see policy-level affirmation. There were two outcomes of this. One, the strategy to use bottomup methods did not pay off. Two, formal legitimisation of the contribution of lower-level staff did not
happen.
Recommendations to PHD of MCGM
A. Sustaining what has been achieved
Gynaecology OPDs:
- sustaining uninterrupted supply of drugs
- provision and maintenance of other equipment and supplies
- filling vacancies
- acknowledging and supporting the role of CHVs, ANMs and MPWs
- continuing with the training and CME activities
- continuing the present arrangement for supervision and monitoring quality of services
Counselling Booth
- Ensuring that staff continue to be in place
- Arranging for supervision and monitoring
- Providing for supplies and maintenance
Taking the next steps in male involvement
- Providing an enabling environment for MPWs to work with men in the community, health posts and
Gynaecology OPDs through appropriate administrative measures and mechanisms
Finalising and implementing the Patients’ Charter
B. Upscaling the efforts
- Gynaecology clinics in all health posts catering to slum populations
- Counselling booths in more secondary hospitals
- Taking the next steps in male involvement; implementing adolescent boys programme in all
health posts in a phased manner
- Extending Stepping Stones training to cover all health providers
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I. Women C entred Health Project j Report of the End Evaluation
Mainstreaming gender and rights in
reproductive health care within a
public health system:
The experience of Women Centred Health Project,
Mumbai
Report of a review and assessment submitted by TK Sundari
Ravindran to the Women Centred Health Project
October 30,2003
LIU
| Women Centred Health Project I Report of the End Evaluation
Table of Contents
Table of Contents
Introduction
Introduction
151
I
Women Centred Health Project: Vision, objectives and interventions
153
The context
153
Origins of the Women-Centred Health Project
154
Project area and population
154
Goal and objectives
155
Approach and strategies
155
Interventions
158
An assessment of the major interventions of WCHP
163
Gynaecology out-patient clinics at the primary care level
163
Counselling booth in the gynaecology OPP ofVN Desai Hospital
166
Working with men
169
Development of gender-sensitive IEC materials
171
Other significant contributions of WCHP
172
Next steps
173
Potential for up scaling WCHP activities with MCGM’s public health department
173
Annex 1: Schedule of Activities during 10-15 August 2003
176
Annex 2: A list of all training conducted during project period
177
Annex 3: The Patients’ rights charter
177
Annex 4: A list of all research studies carried out during the project period
180
I
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p \Vornen^ Centred Health Project I Report of the End Evaluation
Introduction
This report aims to review the work of the Women’s Centred Health Project (WCHP) of the Municipal
Corporation of Greater Mumbai (MCGM) and its contribution to promoting women’s access to reproductive
health services among the population covered by the project.
The review specifically examines
The extent to which project objectives were achieved
How MCGM’s Public Health Department may build on the experiences and achievements of
WCHP
The role of projects such as WCHP in the current national and international context especially in
terms of their contribution to the discourse on gender and rights
Data and information for writing this report were gathered from the following sources:
Review of published and unpublished reports of WCHP, including internal evaluations
Group meetings and discussions with WCHP team, and detailed one-on-one interviews with
team members
Meetings and discussions with health personnel of MCGM associated with the WCHP: some
group meetings and several detailed one-on-one interviews
Visits to counselling booth and gynaecology OPDs run as part of the WCHP
Meeting with senior officials of MCGM to present preliminary findings and obtain detailed feedback
Document reviews were carried out in the first two weeks of August 2003, and this was followed up with
a one-week visit to Mumbai during 10-15 August 2003. (See Annex 1 for activities carried out during this
week).
This report is divided into three sections. The first section describes the backdrop against which WCHP
emerged, the project's objectives, and the scope and range of its interventions. Section two presents
findings, observations and reflections of this reviewer on the achievements of specific interventions. The
larger questions related to the potential for up scaling WCHP’s interventions within the MCGM’s health
services, and the relevance and significance of projects such as WCHP in the national and international
contexts are addressed in section three.
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Women Centred Health Project: Vision, objectives and
interventions
The context
The International Conference on Population and Development (ICPD) held in Cairo in 1994 was a landmark
in the history of the women’s health and rights movements. It brought about a major paradigm change
from the ‘population control’ and fertility reduction agendas of previous conferences, to one that placed
women’s rights and empowerment at its centre, thanks to the efforts of the international women’s health
movement and other coincidental historical factors1,
The ICPD Programme of Action stated that
“Advancing gender equality and equity and the empowerment of women, and the elimination of all forms of
violence against women, and ensuring women’s ability to control their own fertility, are corner-stones of
population and development programmes.” (Principle 4 of the ICPD Programme ofAction)
It further recommended that men be encouraged and enabled to take responsibility fortheir sexual and
reproductive behaviour and their social and family roles.
The agreements reached about reproductive health and rights of women in the ICPD programme of Action
were reiterated in the Platform for Action of the Fourth World Conference on Women (FWCW) held in
Beijing the following year. The Beijing Platform for Action added to these the need for equal relationship
between women and men in matters of sexual relations and reproduction.
In terms of planning and implementing reproductive and sexual health programmes, operationalising
Cairo and Beijing agreements meant taking into account a number of gender issues. It called for
acknowledging and addressing the fact that women’s fertility behaviour is determined not only by their
knowledge of methods and access to services, but by their subordinate status in society and their
inability to make decisions about their lives. Services needed to be client-centred, and go beyond family
planning to address women’s essential reproductive health needs. This would include interventions that
cater to adolescent girls as well as women beyond the reproductive age group. Further, reproductive
health and family planning could no longer be treated as a “women’s only” concern. Programmes were
challenged to involve men in sharing the burden of contraception, and also to encourage them to be responsible
and supportive partners to women in preventing and managing reproductive and sexual health concerns.
ICPD also upheld reproductive rights. This translated in practical terms into voluntary choice in marriage
and family formation, the right to decide the number, spacing, timing of children, and have the information
and the means to do so; access to safe contraception, good information and follow up; freedom from
sexual coercion and violence; and the right to safety in childbirth and from infections related to sexual
activity such as RTIs and STIs and HIV/AIDS.
1 These included, for example, the fierce opposition from the Vatican and other conservative forces, which brought together
the women’s health activists and the Family Planning NGOs and demographers to present a common reproductive health and
rights agenda. The US administration at that historical point was also in favour of women’s rights including their right to control
their fertility and to have access to abortion services.
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About the same time as the ICPD, a paradigm shift was also occurring in the family planning programme
in India. The need to move away from a demographically driven and target-oriented population control
programme had been advocated for by women’s groups, researchers and academicians and recognised
by senior policy makers. With the impetus received from ICPD, this resulted in the ‘Target Free Approach’,
which removed top-down targets in family planning programmes. Simultaneously, a ‘Reproductive and
Child Health’ (RCH) programme was also developed and launched in 1997, with the support of funding
from the World Bank. In Mumbai, the first phase of the RCH programme was implemented in 2000
(PLEASE VERIFY), and has consisted mainly of staff training and orientation to the paradigm shift. There
is a possibility that the programme will continue for a second phase (RCH-2), to implement the provision
of essential reproductive health services starting from the primary care level.
Origins of the Women-Centred Health Project
The Women-Centred Health Project (WCHP) evolved organically from a research project carried out
during 1993-96 by the MCGM in collaboration with the Women’s Health Group of the Liverpool School of
Tropical Medicine. This research project examined the prevalence of pelvic inflammatory diseases (PID)
in women from low-income settlements of Mumbai from a clinical and epidemiological perspective and
also documented women’s own expressed reproductive and sexual health needs.
The findings from this research project made it clear that there was a huge unmet need for women’s
reproductive and sexual health care among women from low-income settlements, and paved the way for
the creation of the WCHP.
The architects of the WCHP were among those who had for long championed women’s reproductive and
sexual health rights. The supportive political climate internationally and within the country for these ideals
made it possible for the WCHP to attempt to operationalise the principles of gender and rights in reproductive
and sexual health and health care. Several such initiatives independently evolved in many different countries in
response to local needs and found support because of the shift in perspective of policy makers following ICPD.
The project is collaboration between four organisations. These are the Municipal Corporation of Greater
Mumbai (MCGM), SAHAJ, a non-governmental organisation (NGO) based in Baroda, the Liverpool School
of Tropical Medicine (LSTM) and the Royal Tropical Institute (KIT), Amsterdam. The WCHP is an
independent unit located physically and structurally within the MCGM. It has three principal investigators
- Renu Khanna from SAHAJ, Korrie de Konig from KIT and Dr Usha Ubale from MCGM, who is also the
project co-ordinator.
Project area and population
WCHP works mainly in two of the 24 wards of the MCGM, G-North and H-East. The total population of
these wards is estimated to be a little over one million. G-North covers Mahim, Matunga, Dharavi and
Dadar while H-East includes the area between Bandra and Santacruz.
The population served by MCGM’s health facilities belong to low-income groups. People live in one ortworoom tenements with common toilet facilities, shacks and huts or even on the pavement under temporary
shelters. Petty trading and vending, and casual wage labour are the main occupations of those employed.
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While an earlier study carried out in another low-income settlement of Mumbai had reported that 75% of
women experienced symptoms of gynaecological problems2, the RID research project had found that a
vast majority of women’s reproductive health problems went unattended. There was urgent need for
dissemination of accurate and relevant information of reproductive and sexual health, and availability of at
least essential reproductive and sexual health services at the health post level, and effective referral services.
Goal and objectives
The project's goal was to ensuring quality health care services for women, within the context of their
reproductive health and rights.
Major objectives
•
Improve, strengthen and increase the quality and range of health care services for women at all
•
levels
Enable women to have access to gender-sensitive and user-friendly health services
•
Raise awareness and sensitivity on women’s health, reproductive rights, gender issues, and
increase knowledge of women’s health among men and women in the community, health workers
•
and service providers of MCG M
Develop and build the capacity of staff at the two wards of the MCGM in training, monitoring and
evaluation and evaluation on issues related to women’s health and reproductive rights
Approach and strategies
The WCHP adopted a ‘health systems’ approach to achieving its objectives. Accordingly, rather than set
up an isolated project which functioned under unreal circumstances, its strategy was to develop a replicable
model for strengthening the capacity of the health system as a whole to better cater to the needs of the
population it serves, and especially women. The project sought to create a sustainable system of delivery of
reproductive health care services, and also mainstream a gender and rights perspective within these services.
Four major strategies were seen as important for realising these approaches within the specific
interventions undertaken by the project:
Working within the MCGM’s structure and its existing health facilities
and involving senior decision-makers and health managers in planning for
and implementing interventions and activities
Capacity building of staff at various levels in counselling, communication, training skills, quality
assurance, gender issues, and clinical skills
Promoting quality assurance and respect for patient rights
Research to support development, monitoring and evaluation of interventions
2 VB Malgaonkar, IG Parikh, VR Taskar, ND Dharap and VP Pradhan. Perceptions of Bombay slum women regarding refusal
to participate in a gynaecological health programme in Listening to women talk about their health- Issues and evidence from
India, The Ford Foundation, 1994.
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Working within MCGM’s existing health facilities
The project works through the health facilities of MCGM in these two wards. These include one hospital:
the VN Desai Hospital, two maternity homes within which post-partum centres are located, and primary
care centres: 18 dispensaries and 17 health posts. The dispensaries provide mainly curative services and
drugs, while the health posts provide family planning and maternal and child health care services (FP/
MCH), tuberculosis control activities as part of the Revised National Tuberculosis Control Programme
(RNTCP) and also carry out outreach activities.
The health personnel with whom the project worked in order to implement project activities included
besides the senior management of MCGM several layers of MCGM health providers such as consultants
and staff of the hospital and maternity homes, the Medical Officers -Health (MOH) in-charge of each
ward, the medical officers in the dispensaries, full-time medical officers (FTMOs) heading health-posts,
Public Health Nurses, female auxiliary nurse midwives (ANMs), male multi-purpose workers (MPWs) and
community health volunteers (CHVs) who do the community out-reach work.
As already mentioned, a senior official of MCGM is the project co-ordinator and one of the three principal
investigators. In addition, there are a number of groups and subcommittees, which involve MCGM, staff
from various levels in the planning, implementation and monitoring of various activities. Some examples
include the Support Group constituted of senior officials of MCGM, the Working Group with Assistant
Health Officers in-charge of specific health programmes within MCGM, the Clinical sub-committee, the
IEC Core Committee, and Men’s Involvement Committee
Capacity building of staff
This was a massive undertaking, with training conducted for all levels of staff on a wide range of topics
throughout the project period. During the six years of the project, training has been conducted for clinicians,
laboratory technicians, PHNs, ANMs, MPWs, CHVs, administrators from MCGM, and for key trainers of
the RCH programme being implemented in Mumbai. Topics covered included clinical skills in treating RTI/
STDs, menstrual problems, antenatal care and infertility, quality assurance, gender and health,
communication, social aspects of reproductive health, counselling for MTPs and family planning,
communicating about sexuality and HIV/AIDS, development and use of IEC materials, participatory training
techniques. The training methodology was participatory and all the training workshops adopted awomen-
friendly, women-centred approach (See Annex 2 fora list of all training conducted).
In addition, continuing medical education (CME) sessions were held monthly in both the wards starting
November 1998. Medical officers from health posts, dispensaries and maternity homes attended these
sessions in which they discussed cases seen in their health facilities and received guidance from the
‘honorary’ consultants who were specialists. In every CME, clinicians made presentations on cases on a
previously decided health problem.
WCHP also contributed significantly to capacity building of health personnel beyond the two wards in
which its work was focused. This was done through the training of key RCH trainers, working towards
integrating sessions on gender, counselling skills, quality assurance and facilitation skills in the integrated
skill development training of medical officers in RCH. WCHP staff was also key-trainers in the training of
personnel involved in the Adolescent Girls’ Initiative, a reproductive and sexual education programme for
out-of-school adolescent girls started by the Public Health Department of MCGM.
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Promoting quality assurance and respect for patient rights
Given the central importance given to quality of care and rights issues in the ICPD Programme of Action,
WCHP undertook the major challenge of introducing and encouraging the adoption of quality assurance
within the health facilities of MCGM. Mainstreaming quality assurance within the system was seen as
fundamental to the task of mainstreaming a gender and rights perspective in reproductive health care.
Between 1997 and 2001, a series of six quality assurance workshops were held for health staff from the
two project wards. Three areas were prioritised for action, namely referral, provider-client communication,
and drug monitoring. Systems were innovated to make the referral chain work more effectively and to
monitor drug indenting and utilisation; training workshops were conducted to improve provider-client
communication. Other issues impacting on quality of care were staff shortage, delays in maintenance
and repairs, cleanliness, and functional co-ordination between dispensaries and health posts when the
two were located under the same roof.
As part of Quality Assurance, WCHP made some important contributions to the management information
system (MIS). A set of quality criteria was developed with standards and quality indicators for each
service being provided by the dispensaries and health posts, and explanations provided on how these
could be made operational. It also developed a family card as an alternative to baseline register and
suggested ways of avoiding duplication of reports.
A great deal of energy was spent in ensuring the participation of health personnel in identifying the quality
issues as well as coming up with ways to address these. Tools and checklists were developed through
participatory processes to monitor quality and to grade health facilities according to whether or not they
met the quality criteria. It was hoped that this process would ensure buy-in from those responsible for
making change happen.
Gender mainstreaming in the quality assurance process was attempted through training workshops for
health care providers on key gender concepts, social determinants of women’s and men’s health, and a
rights approach to health, and in particular, to reproductive and sexual health.
One important outcome of the quality assurance process was the evolution of a Patients Charter of Rights
and Responsibilities (See Annex 3). This was seen as a critical tool for
Developing accountability and transparency of the system
Generating demand for services
Obtaining clients’ perspectives on quality of care
Paying attention to the gender dimensions in quality of care
The Patients Charter is however yet to be adopted by the MCGM at the time of writing this report.
WCHP also deemed it very important to empower patients so that they would demand quality in health
services and hold the health system accountable to those they serve. The project intended to increase
clients’ knowledge of MCGM health services offered at different facilities, and also to improve their knowledge
of women’s health issues and of reproductive rights. It further sought to improve men’s knowledge and
f Women Centred Health Project | Report of the End Evaluation
sensitivity regarding women’s health issues and encourage men’s participation in women’s health and in
sharing responsibilities. However, progress in thus empowering patients has been limited for a number of
reasons, to be discussed in the next section.
Research to support development, monitoring and evaluation of interventions
One of the unique features of the WCHP is its systematic approach to designing interventions and
activities, monitoring and evaluation. Every intervention was preceded by a base-line survey, which assessed
needs and gaps, and this information was shared with MCGM officials and staff, and used in participatory
processes for designing interventions. Studies were also carried out while an intervention was being
piloted, and suitable modifications made to the intervention on this basis. There have also been evaluation
studies at the end of the project period in 2003 to assess project outcomes.
There have been base-line studies on community needs and expectations from the health care system,
on male involvement in reproductive health, on the way the drug system functioned within health facilities,
on quality of care in and infrastructural adequacy of health facilities, on the need for counselling in the
referral hospital, and so on. A large number of studies were carried out specifically around quality issues
in health facilities at all levels, as mentioned in the previous section on quality assurance.
There have been base-line surveys on the number of gynaecological cases seen in OPDs prior to the
starting of the specific OPDs, mid-term and end line assessment of the number of patients utilising these
services afterthe project has been initiated. FGDs have been conducted on patient satisfaction with the
OPDs as well as to find out reasons for non-use from community members who did not use the services.
Studies were carried out also to support the development of IEC materials, and to develop activities
around male involvement in reproductive health (See annex 4 for a list of all studies carried out during the
project period).
Interventions
While numerous activities were undertaken by the WCHP in response to the evolving needs of the MCGM s
health services, four major interventions may be highlighted as forming the core of WCHP's activities:
•
Establishing gynaecology out-patient clinics at the health posts
•
Establishing a counselling booth at the VN Desai hospital
•
Working with men
•
Developing gender-sensitive IEC materials
Establishing gynaecology out-patient clinics at the health posts
Making high-quality essential reproductive and sexual health services available and accessible to lowincome women has been perhaps the most important objective of WCHP. Capacity building of staff,
promoting quality assurance and designing interventions on the basis of evidence gathered from the
patients and clients, as well as working within the MCGM structure have all been motivated by the desire
to put in place such services on an on-going and sustainable basis.
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In general, low-income women in urban Mumbai do not have access to basic reproductive health services
(besides antenatal care) in health posts. Although the FTMOs in health posts did treat gynaecological
conditions, patients were usually referred to maternity homes and post-partum centres for laboratory
investigations and treatment. Drugs for treating RTIs and instruments for performing pelvic examinations
were not available in many health posts. As a consequence, many women were not able to access
effective treatment for gynaecological problems.
WCHP’s intervention sought to make available treatment for minor gynaecological problems at the health
post level, so that women did not go untreated for these. The first of these OPDs began to function only
in 2001, several years after the project was started. An important lesson learned was that a great deal of
preparatory work was needed before even a seemingly simple task such as designating one day exclusively
for gynaecology OPD could be operationalised.
The first major step was training. Medical officers from health posts and dispensaries and ANMs, MPWs,
CHVs and laboratory technicians received comprehensive training on gender and health, communication
and counselling, and clinical skills development in four reproductive health needs and problems, namely
antenatal care, menstrual disorders, reproductive tract infections and infertility. This was followed up with
regular continuing education sessions to upgrade clinical skills.
Project personnel had originally believed that given the training input, the medical officers would initiate
gynaecology OPDs at their respective health posts and dispensaries. It soon became clear that there
were many more steps to go before this would be possible.
As a second step, a facility survey was undertaken to document the infrastructural facilities and equipments
and drugs available in health posts. Health posts with the following essential pre-requisites were to be
identified as eligible for starting the gynaecology OPDs:
Privacy for PV examination, adequate water supply and toilet facilities for clients
A medical officer and at least 50 per cent of all sanctioned staff in place
Availability of steriliser and instruments for carrying out gynaecological examination
Ensured supply of drugs for the management of the selected reproductive health conditions
The number of health posts that satisfied these criteria was very few. Consequently, the project made
efforts to procure instruments for gynaecological examinations from within the MCGM system. Another
important move was to liasewith Mumbai District AIDS Control Society (MDACS) to ensure regular and
adequate supply of drugs for treating RTIs. Four most commonly required drugs have been regularly
supplied by MDACS to the gynaecology OPDs over the two years during which these OPDs have been
functioning. In addition, modest investments were made by WCHP for procuring other necessary
prerequisites such as curtains for ensuring privacy, and a WCHP staff person has been appointed mainly
to help trouble shoot in the OPDs. This person arranges for immediate repairs and replacements of equipments
and instruments, ensures regular drug supply through MDACS and also deals with other contingencies.
Monthly supervisory visits are made to the gynaecology OPDs by consultants working in peripheral
hospitals of MCGM to monitor the quality of services. A supervisory checklist developed by WCHP for
this purpose ensures a systematic approach to supervision and quality assurance.
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Establishing a counselling booth at the VN Desai hospital
In response to the expressed need by health providers as well as clients and women in the community for
better information and counselling services, a counselling booth has been set up attheVN Desai hospital,
which is an MCGM general hospital. This counselling booth is located within the obstetrics and gynaecology
OPD of the hospital, with one WCHP staff member providing counselling services.
The counselling booth is an enclosed space offering adequate privacy to the client. It is located right at
the entrance to the OPD and has a sign on its door that explains its functions. Women are encouraged to
walk into the counselling booth on their own initiative. In addition, patients are referred for counselling by
the doctors attending the OPD. A clear protocol on which patients have to be referred for counselling has
been developed for use by the doctors and consultants. Women referred for counselling are usually family
planning and Medical Termination of Pregnancy (MTP) clients.
A manual has been developed in consultation with a wide range of specialists and women’s rights activists
on women-centred counselling techniques. Two ANMs who have received training in counselling have
been appointed as counsellors. Both were originally part of the PID research project and have been on the
staff of WCHP since its inception.
In addition to these counsellors, ANMs and MPWs who undergo counselling training are placed in the
counselling booth for practical experience. The MPWs counsel men accompanying the women to the
obstetrics and gynaecology OPD at the hospital in a space outside the OPD, while the ANMs sit in the
counselling booth alongside the regular counsellor. A suggestion box has been kept outside the counselling
booth to receive feedback on the quality of services and to learn about any problems or concerns.
Working with men
This intervention is aimed at promoting understanding by men of women’s and their own reproductive
health conditions and problems, and encouraging them to support women in seeking health care and in
addressing their reproductive health needs problems. This approach is clearly different from the usual
‘men’s involvement means more vasectomies’, or approaches which contribute to further consolidating
men’s control over women’s sexual and reproductive health.
The activities that were initiated as part of this intervention may be divided into
Exploratory and formative research to understand better how to work with men and to develop
interventions
Capacity building with the male health workers (MPWs) as a preparatory step for working with men.
Research has been conducted with service providers and with men and women in the community. Indepth interviews conducted with MPWs and ANMs intended to explore the possibility of involving MPWs
in work with men in the community.
The study revealed that their present work situation offered MPWs little opportunity to interact with men,
because men were away at work during the working hours of the MPWs. The study also indicated the need
to sensitise health care workers on gender and health and on the role of men in women’s reproductive health.
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Another study was carried out with men in the community and their partners to understand the role men
currently play in women’s reproductive health, and to identify men’s own information needs in the area of
sexual and reproductive health. The study found that men’s current role in women’s reproductive health
was in the best case scenario limited to providing financial and emotional support and helping with
household chores. The study did not provide much insight into men’s information needs except to indicate
that men knew very little about the details of the health problems or conditions that their wives experienced,
such as caesarean sections, sterilisation or MTP.
MPWs are the only male outreach workers within the Public Health Department, and form the first line of
contact with men in the community. However, as confirmed by the exploratory study, MPWs have rarely
worked with men on sexual and reproductive health issues. Moreover, their own information and skill
levels on these topics is limited, as also their awareness on gender and health. Building capacity of
MPWs to work with men on gender, reproductive and sexual health is therefore an important prerequisite
for enabling work with men in the community on sexual and reproductive health. However, this proved to
be a major challenge, and several hurdles had to be crossed before MPWs were willing to participate in
training workshops.
Training workshops have been conducted to introduce concepts and build perspective on gender, sexuality
and health, and develop communication, counselling and facilitation skills.
Male Involvement Committees (MICs) have been constituted with MPWs as members. This committee
brainstorms ideas and develops interventions for working with men and boys in the community. An
assessment of activities that have emerged from this process is presented in the next section.
Developing gender-sensitive IEC materials
Making available accurate and gender-sensitive information on reproductive health issues is seen by the
project as an essential part of addressing reproductive rights. Development of gender-sensitive IEC materials
through a participatory process is therefore an important component of the project.
The IEC component became operational only in July 1998, with the appointment of an IEC officer. This
intervention began with a review of existing material produced by the IEC cell of MGCM. It was found that
the material produced was not easily understood by members of the community and did not take into
account gender and other social determinants of health. The materials had also not been produced based
on an understanding of community’s information needs, or through a participatory process, because of
numerous administrative constraints.
In keeping with its strategy of developing health system capacity, WCHP constituted an IEC Core Committee
from among staff of the IEC Cell and organised training workshops for its members on the principles of
participatory material development. Another workshop demonstrated the process of developing IEC material
with inputs from members of the community.
Four gender-sensitive IEC materials for use in the community have been produced by the project. These
are a broad sheet and a pamphlet on RTI, a pamphlet on MTP and flannel graph on antenatal care.
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Let us take the example ofthe RTI broadsheet Mahitichi Bagicha to illustrate the painstaking process of
material development. As a first step, FGDs were carried out with women in the community to ascertain
the medium of communication preferred by them, and also to assess their information needs regarding
RTIs. It was found that the women preferred communication media that allowed for interaction with the
person providing the information. It was therefore decided to use the format of a broad sheet to develop
IEC material on RTIs. The next step waste review all available material on RTIs. After this, the content of
the broad sheet was developed, and a draft version prepared. This version was reviewed by health workers
as well as the IEC ‘Core Committee’ which included members from MCGM’s IEC Department. This led to
a second draft, which was pretested in the community for appropriateness of illustration, language and
layout. Only then was the broad sheet finalised and printed. This was not all. Training workshops were
organised for ANMs, CHVs and MPWs on how to use the broadsheet as a health education tool for
members ofthe community.
By mid 2003, considerable investment had been made in building the capacity of the health system to
provide information and services related to reproductive and sexual health services at the primary level,
assuring good quality and gender-sensitivity. In the next section, we present an assessment of the
achievements of the major interventions described above, and of the project’s progress towards meeting
the objectives it started out with. The section also discusses the potential of these interventions for up
scaling within the MCGM. This assessment is based mainly on reviews of documents, interviews with
staff ofthe project, MCGM staff and clients; and reflections and observations ofthis author.
| Women Centred Health Project I Report of the End Evaluation
II
An assessment of the major interventions of WCHP
Gynaecology out-patient clinics at the primary care level
Adequacy of infrastructural facilities, equipments, drugs and supplies
By August 2003, there were eight gynaecology OPDs being held once a week, seven of these in health
posts and one in a dispensary. The facilities were modest, but met the requirements for conducting
gynaecology OPD. For example, all facilities had a separate room for Copper T insertion and adequate
privacy for performing pelvic examinations.
According to the end-line evaluation study carried out in 2003, all necessary equipment were available
and in working order in four of the eight facilities, and in two others, only small items such as torch and
weighing machine were not working. Many items had been supplied to these facilities as part of the
project: BP apparatus, stethoscopes, gloves, examining lamps and curtains, to mention a few. In two
facilities, there were several equipments that were in need of repair or replacement.
The study also found that there was regular supply of drugs required for treating a number of reproductive
tract infections from MDACS to all these facilities. Drugs supplied included the following: Candid V1
pessary, Doxycyclin, Flucanozole and Metronidazole. In addition, MDACS also sometime supplied
Erythromycine, Azithromicine and Candid cream. However, in all but two of the eight facilities, drugs that
were part of the schedule were in short supply or had stocks exhausted.
In terms of staffing, in two facilities the gynaecology OPDs were being conducted by the medical officers
of the dispensary, in four there were full time medical officers available, and in two others, FTMOs were
available for only some of the days because they were attending to more than one health post because of
staff vacancies. I nail except one facility there were one or more ANMs, MPWs and one PHN.The number
of CH Vs varied between 10 and 23, except for one facility (Colaba ‘A’) that had only 2 CHVs attached to it.
Utilisation of facilities
The gynaecology OPDs were in general well utilised by the population in the target area. Information
available from six health posts showed that 1001 clients utilised these clinics during April 2002-March
2003, with an average attendance of 8 clients per OPD. There were, however, variations across health
facilities in the average number of clients seen, from about 12 to as low as three. Clinics that have been
functioning since 2001 seemed to have a higher average number of clients (12 and 9 respectively) while
clinics that have been functioning for only a few months had the lowest average number of clients (four and
three respectively). Preliminary results from a survey conducted in 2003 showed that about 46% of the
women were seeking medical help for symptoms suggestive of reproductive tract infections and menstrual
problems: white discharge, lower back pain or lower abdominal pain; itching, boils or swelling on the
vagina, and irregular periods/excessive bleeding. Adolescents were also attending the OPD, according to
oral reports by health providers. Thus, the gynaecology OPDs are meeting an important need for reproductive
health care.
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Utilisation by women in the community of gynaecology OPDs owes a great deal to the mobilising role
played by CHVs. This fact is acknowledged by the FTMOs and MOs and the MOH, who appreciate the
considerable skill that CHVs have gained in talking to women about sexual and reproductive health and
counselling them to seek medical help. CHVs often accompany women to the gynaecology OPD, which
in itself would make a difference to whether or not a woman actually arrives at the clinic. I met large
groups of CHVs in two of the three OPDs that I visited. They described case histories of patients they had
brought to the OPD, and talked about their confidence and comfort in talking about sexuality and reproductive
health issues to women in the community.
“After the training we know better, we explain better to the women so they come (to the gynaecology
OPD).”
The shortage of staff, which required FTMOs to attend to more than one health post, was an important
factor affecting utilisation of the gynaecology OPDs. The absence of a doctor when the women come
specifically because they have a gynaecological complaint discourages future visits and reinforces their
low expectations from government health facilities. In facilities where the dispensary was under the same
roof and the dispensary doctor was willing to attend to the gynaecology OPD patients, the problem was
mitigated to some extent. This was the case in SV Nagar Health Post when I visited it. I was told by the
CHVs that for most women, the fact that the dispensary doctor was male did not matter very much, what
they cared about was proper check-up and dispensing of drugs. However, they added, women from some
communities did not feel comfortable being attended to by a male doctor and often went back without
seeing the doctor. Also, since the dispensary MO had to first see all his own patients, the waiting time
was very long, and this was inconvenient to many women.
Utilisation of the gynaecology OPD was also not very easy for women who were engaged in wage
employment, according to reports from CHVs. Missing a day’s work was unaffordable and they often did
not come to the clinic despite having reproductive health problems.
Quality of care
According to the staff of the health posts and the FTMOs, between 80-90 per cent of all cases seen in the
gynaecology OPDs were being effectively treated at this level, without need for referral. The regular
availability of appropriate drugs was cited as an important factor contributing to effectiveness of treatment.
Patients, who came for prolapse, cervical erosion, fibroids and symptoms suggestive of cervical cancer,
and for infertility, were referred to the nearby hospital. The CHVs followed-up referral cases and the
FTMOs also tried to keep track of the outcome of referrals.
In conversations that I had with two clients, I learnt that they had tried ‘private’ doctors and private clinics
for their white discharge problems but did not get cured. They had come to the health post and got cured.
Moreover, the treatment was free, and the facility was close to home. This is corroborated by findings from
a survey in 2003 carried out in six health posts, in which clients reported availability of drugs free of cost,
and the nearness of the facility as major positive factors of the gynaecology OPDs.
Provider- client relationships were very good, according to reports by users in the above-mentioned survey
carried out in six health posts. All respondents (n=50) said that the doctor listened to what they said, and
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that they could talk ‘freely’ with the doctors about their complaints. Indicators of ‘listening’ included,
according to the respondents: maintaining eye contact, asking pertinent questions, and writing down
their complaints carefully.
One client I spoke to had come for a check-up one week after she had had Copper-T inserted. She did not
belong to the ward in which the health post was located, but had come because she had heard good
things about it from a relative who is a user of the health post. She appreciated the information she had
received on the different methods of contraception, the careful ‘check-up’ by the doctor before insertion of
Copper-T and the advise given to make a return visit the next week. She felt that the care she received
was much better than ‘private’.
Another important issue concerns partner notification. In two of three gynaecology OPDs that I visited,
FTMOs as well as ANMs, the MPW and CHVs reported that drugs for the husband were sent with the
woman seeking treatment for RTIs. Both the CHV and the MPW tried to help the woman by talking to her
husband about compliance with treatment. Health providers were of the opinion that in a large number of
instances the men did indeed take the drugs. However, there was no systematic monitoring of partner
treatment, and this situation could be improved.
I spoke to and observed two FTMOs at work in their gynaecology OPDs. Both were young women doctors
with a high level of motivation and commitment. They discussed their hopes and concerns for improving
the care received by the women they served. One of them had just referred two women to a referral
hospital on that day - one for fibroids and another for second stage cancer of the cervix. She was
concerned that women did not yet seek care early enough to make possible complete cure for cervical
cancer.
Concerns related to partner treatment and effective follow-up of cervical cancer cases was reiterated by
one of the honorary gynaecologists who monitored the gynaecology OPDs in one ward. She felt that more
systematic work was needed for partner notification and treatment. It was her opinion that the MPWs
could do more towards health education for men and partner notification and treatment. She also
recommended effective liaison with the tertiary-care cancer hospital to ensure screening, diagnosis and
treatment for cervical cancer.
As mentioned earlier, quality of care in these clinics are being monitored by honorary gynaecologists from
the maternity homes and post-partum centres. This system seems to work quite well, thanks to the
dedication of the specialists who take their role seriously. They make regular visits to the gynaecology
OPDs, review case records and offer advise and guidance.
Overall, the achievements of the gynaecology OPD may be summarised as follows:
•
Provision of accessible and good quality RH services to poor women at the primary care level
•
Assured availability of drugs for RH problems leading to enhanced patient confidence in the
facility
•
Catering to hitherto underserved groups such as adolescents and older women
•
Dealing with problems that did not receive due attention: RTIs/STIs, Infertility, cervical dysplasia
•
Attempts made to involve men through MPWs trained to be gender-sensitive
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However, more needs to be done within each health post to
•
Extend the range of reproductive health conditions addressed from four to at least six, including
•
cervical cancer and HIV/AIDS
Reach-out more systematically to women in the community with information and awareness
•
raising initiatives.
Better involve MPWs in health education for men in the community and improve partner notification
•
and treatment for RTIs/STIs
Build on efforts made to establish an effective referral system to liase with tertiary care centres
•
such as cancer hospitals
Ensures not only that women go to the referral facility, but that they get appropriate treatment and
•
comply with it
Develop a greater awareness of HIV/AIDS, engage in condom distribution; build on the relationship
established with MDACS to refer clients for Voluntary Counselling and testing for HIV/AIDS
•
Focus more on widening contraceptive choice for women and promoting male methods of
•
contraception
Utilise opportunities available within the health post for counselling, health education and information
dissemination especially with respect to the reproductive health problems being focused on
Also, once gynaecology OPDs begin to function well on a routine basis, more attention may be needed to
ensuring that the training on gender-sensitivity received by health providers becomes mainstreamed into
protocols for history taking, and management of reproductive health conditions and problems. This requires
sustained efforts at training, capacity building and monitoring over a long period of time.
Counselling booth in the gynaecology OPD of VN Desai Hospital
During the eight months of its existence, 350 women and 200 men had received counselling services at
the counselling booth. The counselling booth is equipped with health education materials and a model of
the uterus and female reproductive tract. Women referred for counselling on contraception are given
detailed information on the pros and cons of all methods of contraception, including male methods. They
are encouraged to decide on a suitable method on their own. Once they choose a method, more details are
given related to how the method is administered. Clients are encouraged to ask questions and clarify doubts.
With the consent of the client concerned, I observed one MTP client being counselled. Overall, the
counselling was of very good quality. The counsellor asked the client about herself. The client had two
children and was currently pregnant. She felt that she was ‘too weak and therefore did not want to go
through one more pregnancy. She said that she had decided to undergo sterilisation after the MTP. The
counsellor then asked her whether she knew how MTP was done. The client did not. The counsellor used
the model of the uterus and reproductive tract and explained the D&C procedure. She then asked the
client to ask for any clarifications. The client wanted to know about the length of the procedure and the
time it took to recover from anaesthesia.
The counsellor then gave a detailed explanation of all contraceptive options available to the woman. She
talked about the condom and vasectomy as well.
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However, the client said that she had decided on female sterilisation. The client then asked the counsellor
whether she would talk to the client’s husband who was waiting outside the OPD. lA man does not
understand what the woman goes through’she said, and so she would like the counsellorto explain to her
husband the MTP and sterilisation procedures and the care she needed after these procedures. The
counsellor readily agreed. The counselling session for this client took more than half-an-hour, and another
half hour or so was spent with her husband. The client expressed satisfaction with the information and
counselling provided.
Discussions with honorary consultants showed that all of them felt that the counselling booth was
contributing significantly to client satisfaction and to compliance with treatment. An earlier evaluation of
the functioning of the counselling booth also found this to betrue overall.
To summarise the achievements of the counselling booth,
•
Comprehensive information and good quality counselling services are provided to women many of
them coming for family planning and MTP services
•
There is informed decision making by clients/patients. An indirect spin-off of this may be that
there is less scope for medico-legal problems
•
The presence of a counsellor who listens to the patients’ problems and provides has improved
doctor-patient communication
•
Greater awareness on the part of RMOs and housemen on patient rights has meant that patients
are treated with greater sensitivity and courtesy
•
Counselling service is considered essential by honoraries as well as junior doctors
•
Patients are highly appreciative of services
However, there are still some issues that are still being sorted out, and there is also potential for further
improving and expanding the scope of services offered.
The constant (once in six months) rotation of Resident Medical Officers (RMOs) and housemen
means that staff have to be oriented on the need for counselling, on patient rights and on gender
issues repeatedly. It may take a long time before they begin to appreciate concepts such as
patients’ right to information and gender-sensitivity. Interviews with RMOs and houseman carried
out as part of the earlier evaluation showed that some of them thought that it would be counter
productive to give too much information to the patients. This is likely to prove a continuing challenge.
•
There is need to appoint a male counsellor, rather than just use the trainee MPWs for counselling
men. This is important for maintaining continuity. Another issue is that currently only clients referred
by doctors may use the counselling services, and there is no direct access to clients to the counselling
booth. This situation needs to change.
A systematic plan is required for upgrading the knowledge and skills of counsellors on an ongoing
basis, including translation into Marathi of technical information on reproductive health problems that
they have encountered in their counselling work. This is essential to maintain the quality of counselling.
•
Currently the two female counsellors take turns to come to the counselling booth on different days of
the week. It may be useful if the two work together on all days, taking turns to be in the booth and be
in the OPD, carrying out health education among women waiting there. Health education may be
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especially important for antenatal mothers who need information about danger signals in pregnancy
and appropriate pregnancy, delivery and postpartum care. Also, an earlier plan to carry out health
education for women in the postpartum ward has not yet been operationalised. The presence of two
counsellors every day would make it possible to undertake this as well.
•
The counselling booth could have more health education materials, for example, about various methods
of contraception, about MTP and so on, including flip charts that can be shown to the women and
pamphlets that they can take away with them for future reference.
•
The suggestion box may be a good idea for ensuring feedback in settings where most clients are
literate and also used to the idea of written communication. In the present setting, it is doubtful if this
would encourage many of the clients to provide feedback. Other means of securing feedback need to
be explored, such as periodic exit interviews.
•
There appears to be some discomfort on the part of consultant gynaecologist that the counsellor is a
paramedic and not a doctor. There is also a concern that the counsellor may not be able to provide
accurate information to the client. Some steps may be taken to allay these concerns, through for
example, involving the consultants in capacity building for and monitoring of counsellors’ work.
•
A rather sensitive issue concerns the role that counsellors ought to play when there is failure of a
surgical procedure or of medical treatment. For example, when a client approached the counsellor
following failure of MTP, the counsellor did not know how to help the woman, because this may turn
out to be medico-legal case with the client litigating against the hospital. Can they afford to be on the
patients’ side without jeopardising the very existence of the counselling booth? This issue needs free
and frank discussions between the counsellors and the hospital staff.
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Working with men
One of the major contributions of WCHP to working with men in the community has been the capacity
building and motivational work carried out with the male MPWs and some Community Development
Officers (CDOs). This was stated by a group of MPWs and CDOs in a meeting I had with them.
The MPWs felt empowered by the gender and health training, and the training on counselling skills. They
had developed a number of other skills that gave them tremendous confidence as community workers.
These included skills such as conducting focus group discussions and planning and enacting street
plays, facilitating training for adolescent girls and collecting case-study materials and problem-solving.
One of them said that he was no longer embarrassed to talk about contraception and sexual health
issues, while another stated that earlier he would never talk to women, but now he had developed the
confidence to do so.
Two training workshops received repeated mention - one conducted by Dr Abhijit Dasgupta and Satish,
and the other, the Stepping Stones training on communicating about sexuality in the community. The first
was appreciated because “the facilitator threw out the plan he had made for the training and addressed
our issues”. The Stepping Stones (SS) training was a major life-changing experience for many of them,
and several MPWs said that the training had changed their attitude and behaviour towards their mother,
wife and children. Another aspect of the SS training was that there were also doctors who participated in
it. The MPWs and CDOs I met felt that participation in the SS training had changed the doctors’ attitudes
to MPWs and CDOs; they now respected them and their views more and treated them as colleagues
rather than as subordinates.
Explaining their initial resistance to WCHP activities, the MPWs said that the very name ‘Women- centred’
conveyed to them an exclusion of men. They were also vary of increased workload, because ever since
their recruitment as MPWs as part of IPP-V, all they had seen was an addition to their workload without
any investment in their development. WCHP’s organising numerous training workshops for MPWs made
them realise that ‘there was also something in it (WCHP) for us. ’
What has been the outcome in terms of work with men in the community, of investing in capacity building
of MPWs? Some of the activities that have been carried out or initiated, with varying degrees of success,
include
Health information sessions on reproductive tract infections conducted for men and adolescent
boys
Development of a training module on reproductive and sexual health for adolescent boys
Counselling at the VN Desai hospital
Health education of men in health posts
Partner follow-up for women seeking treatment for RTIs
•
Health information sessions using the broadsheet on reproductive tract infections (Mahiticha Bagicha)
were reported to have been carried out successfully only by some of the MPWs. There were problems
in contacting men during theworking hours of MPWs. Some formed groups of adolescent boys and
had health education sessions with them, and these were more successful.
i Women Centred Health Project 1 Report of the End Evaluation
Interactions with the MPWs gave me the impression that there was some discomfort with, and
resistance to working with adult men. Opportunities other than in the community setting did not seem
to have been explored, nor attempts made to identify groups of men who were available during
weekdays, because not everyone works in regular salaried jobs. This may be because MPWs need
more guidance and support on how to go about working with adult men and to deal with the challenges
involved. Exposure to other projects where health education is carried out with adult men may be
useful.
Development of a training module for adolescent boys has been a very exciting process for the
MPWs. This was an idea that originated in the MIC, and a group of MPWs and CDOs (the module
preparation committee) spent considerable time and energy reviewing existing manuals and developing
a module suitable for adolescent boys in urban low-income settings.
MPWs and CDOs told me that they were very keen to take this effort forward, by initiating health
education workshops for adolescent boys. Another important suggestion that emerged was to integrate
this module with the current ‘AIDS education’ initiative being implemented in municipal schools. This
possibility needs to be followed up so that a concrete intervention related to working with men will
emerge out of all the effort and investment made.
•
Counselling at the VN Desai hospitaljs another activity in which MPWs who have undergone counselling
training have been engaged fora period of 15 days each. As already mentioned in the subsection on
the counselling booth, at least one male counsellor needs to be appointed on a regular basis, with
others perhaps taking turns to assist this counsellor and get hands-on-training in the process. MPWs
can play a greater role in counselling men also during their visits to the community. In order for this to
be possible, all MPWs working in MCGM need to undergo training in counselling as well as the
Stepping Stonestraining.
•
Health education of men at the health post is currently ad hoc even in health posts with MPWs who
have participated in various WCHP workshops. This is perhaps because not many men actually
come to the health posts. However, at least in places where the health posts and dispensaries are
located within the same premises, more systematic planning and implementation of specific health
education interventions seems possible starting with for example, the four main reproductive health
conditions currently treated in the gynaecology OPDs, and also on contraception and MTPs. It also
seems important to utilise the MPWs’ knowledge and skills acquired in Stepping Stones workshops
to provide education on HIV/AIDS within the health post/dispensary setting.
f
•
Partner follow-up for women seeking treatment for RTIs by MPWs is also ad hoc, happening in some
health posts and not in others depending on whether or not the MPW concerned has taken the
initiative to do so. As mentioned in an earlier sub-section, the FTMO and the ANMs and CHVs take
the initiative to provide the woman concerned with drugs also for her partner, and in some cases this
may be sufficient. However, it may be the same women who are unable to convince their husbands to
start treatment who are also at enhanced risk of repeated infection by their husbands. Leaving the
matter of negotiating treatment compliance to the vulnerable woman may not be the best way to
approach this issue.
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The MIC needs to take on this issue and figure out ways and opportunities for approaching the
sensitive issue of partner follow-up without placing the woman concerned at risk of partner violence.
Overall, there has been a tremendous job of capacity building, but this intervention seems not to have
chalked out a clear set of short-term objectives and a way forward from there to working with men in the
community. Several suggestions have been given above, based on discussions with MPWs themselves,
WCHP staff and my own observations. Some of these may first be tried out in the two wards where WCHP
has worked so far and modified suitable, before being recommended for up scaling.
Development of gender-sensitive IEC materials
The main achievements of this intervention include
The production of some model gender-sensitive health education material
The sensitisation on gender issues and enhancing of technical skills related to participatory
material development received by a core group of members of the IEC cell and ANMs and MPWs
The development of tools for reviewing the gender sensitivity of health education material
The broad sheet on RTIs had been found to be very useful in training CHVs and in conducting health
education sessions in the community, and the feedback received was very positive. It had not been
possible to get similar feedback for the RTI pamphlet. Another pamphlet on MTP was still being finalised.
A number of manuals and research tools produced during the project period also merit publication and
wide dissemination. Other forms of communication besides written material could also have been ventured
into, for example, short video spots on specific health problems. This appears to have been planned for,
but not implemented. In addition, more could be written about each of the components of the project in
more than one form - not just papers for seminars and conferences, but catchy write-ups of a few pages;
profiles of clients benefiting from the project; highlights of the project’s approach and achievements in
specific areas.
Overall, it is my impression that more materials could have been prepared during the project period that
could have been used effectively in the health posts, counselling booth and in the community. This would
perhaps have been possible had the project focused exclusively on production of gender-sensitive IEC
materials through participatory processes. I feel that expending so much time on influencing the IEC cell
was one thing too many for the project to have taken on in the area of systemic change. It is not clear how
the investment made in terms enhancing the technical skills of IEC Core committee members will be
effectively channelled in future.
Without changing the worldview and philosophy of health education in which members of the IEC cell and
the public health department has been schooled, changing the process as well as the content of the
materials produced is not going to be possible. And even if their worldview changed, producing gender
sensitive material is a specialised task that calls for a combination of gender-analysis skills and the
human and material resources required to undertake extensive reviews of research. A more pragmatic
approach even for the future would be to identify a suitable institution or organisation which will be able to
develop such material and supply to the Public Health Department, to supplement the materials already
being produced by the IEC cell of the department.
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Other significant contributions of WCHP
Besides the achievements through the major interventions undertaken by WCHP, the project has made
lasting contributions to the health care delivery system of the MCGM in many areas.
It has been observed in many sections above that capacity- building activity especially in the area of
gender, reproductive and sexual health have made a deep impact on medical officers as well as MPWs,
ANMs and CHVs. The foundation has been laid for building a rights-based approach to providing reproductive
and sexual health services through the communication and counselling training workshops. WCHP’s
inputs have also gone into the RCH training, including in the training of key-trainers. Through this, the
message will spread to a much wider group of health providers.
WCHP’s efforts to mainstream quality assurance within the MCGM’s health services have been among
the first in this area to reach a wide range of health providers. Health providers came together for the first
time to learn about quality assurance and jointly plan for operationalising it within their own settings.
Awareness-raising and skill development have indeed been achieved. However, implementation of QA
principles is probably happening only in the gynaecology OPDs in the health posts and in VN Desai
hospital, including in the counselling booth.
While it was important to work on the area of quality assurance, the project would probably not go about
it in the same way if it had to start all over again. Rather than focus on ‘quality’ in an all encompassing
sense, covering all aspects of all services within a facility, the WCHP would perhaps introduce the quality
assurance workshops within the specific context of running the gynaecology OPDs within health posts.
Defining what quality meant in this specific context and working towards implementing good quality
services would perhaps have been more tangible.
A significant number of tools and processes for quality assurance and monitoring have been developed by
WCHP through an elaborate process of consultation with all stakeholders. These tools are valuable and
may be fine-tuned and disseminated more widely. Workshop modules on quality-assurance training could
probably be developed based on the workshops conducted by WCHP, and field-tested in other settings.
WCHP’s extensive research activities have always been associated with a specific activity or intervention.
Much effort has gone into the development of protocols, methodologies and instruments for data collection
for a variety of purposes, from assessing community members’ information needs to review the gender
sensitivity of health education materials. It seems important to systematise and bring out as publications
these various tools, which have been carefully developed and validated.
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ni
Next steps
Potential for up scaling WCHP activities with MCGM’s public
health department
Having examined the achievements of various interventions that WCHP has experiments with during the
six years of its existence, we now argue that it is important for MCGM to integrate WCHP’s interventions
and activities within its structure, and also upscale in a phased manner the activities now restricted to two
wards to all the wards in MCGM area.
Rationale
What are the tangible health benefits of sustaining and up scaling the WCHP experiment?
WCHP’s experiment has demonstrated that it is possible to effectively treat common reproductive health
problems such as RTIs at the primary care level, and to detect and refer conditions such as cancer of the
cervix in the early stages. Use of reproductive health services by hitherto under-served groups also appears
to increase.
Services available closer to home means and free of cost means that the poorest women are able to use
it. Because health posts are not as overcrowded as general hospitals, there is more time available for
interaction with providers
Provides scope for building rapport and a trusting relationship between the women and the health
providers: ‘In the hospital no one knows us, each time we go there is a new doctor. We feel
comfortable here’.
Rapport between the medical officers and the women in the community would influence women’s utilisation
of services and adherence to treatment. Women who had been vary of accepting contraceptive methods
such as the IUD for reasons related to poor quality of care and lack of trust in health services would now
feel encouraged to use these methods.
Counselling and health education services provided at general hospitals, maternity home, health posts
and through community outreach services could prevent discontinuation of treatment; non-compliance to
treatment and medical advise; incorrect use of drugs; undesirable outcomes such as post-surgical
complications arising from lack of information on appropriate care, and so on.
Similarly, the work with men by MPWs has the potential for reducing unwanted pregnancies; increasing
contraceptive use; promoting male compliance to treatment for RTIs, implying better cure rates and
reduced scope for reinfection; adherence to safer sex practices and prevention of HIV infection.
This approach is also cost effective and efficient. Effective treatment of majority of RH complaints at the
primary care level represents huge cost savings to the health care system because fewer will approach
tertiary and super-specialty hospitals. This also means more efficient use of resources because of reduction
in discontinuation of treatment, recurrence of problems, etc.
j
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| Women Centred Health Project I Report of the End Evaluation
What needs to be done?
The first step is to ensure that what has already been put in place be sustained. As far as the gynaecology
OPDs are concerned, this would mean sustaining uninterrupted supply of drugs from MDACS or other
sources; provision and maintenance .of other equipment and supplies; and filling vacancies.
Sustaining gynaecology OPDs with the same level of efficiency would not be possible without
acknowledging and supporting the role of CHVs, ANMs and MPWs. Training inputs at all levels need to
be continued, including Continuing Medical Education (CME) activities. The present arrangement for
supervision and monitoring quality of services also needs to continue.
Staff in the counselling booth, who are on deputation from MCGM have to continue to be in place so that
the counselling booth continues to function. Suitable arrangements need to be made for supervision and
monitoring of the quality of counselling. It would also be important to provide an enabling environment for
MPWs to work with men in the community, health posts and gynaecology OPDs through appropriate
administrative measures and mechanisms.
WCHP’s experiment has demonstrated that it is possible to effectively treat common reproductive health
problems such as RTIs at the primary care level, and to detect and refer conditions such as cancer of the
cervix in the early stages. Use of reproductive health services by hitherto under-served groups also appears
to increase.
Services available closer to home means and free of cost means that the poorest women are able to use
it. Because health posts are not as overcrowded as general hospitals, there is more time available for
interaction with providers
Provides scope for building rapport and a trusting relationship between the women and the health providers:
7n the hospital no one knows us, each time we go there is a new doctor. We feel comfortable here’.
Rapport between the medical officers and the women in the community would influence women’s utilisation
of services and adherence to treatment. Women who had been vary of accepting contraceptive methods
such as the IUD for reasons related to poor quality of care and lack of trust in health services would now
feel encouraged to use these methods.
•
A rights approach to reproductive health also calls for developing and making available gender-sensitive
and technically sound health education and information material not only to clients, but also to staff
at various levels. WCHP’s approach has shown how this may be done in collaboration with the health
sector staff, and how useful it can be for clients as well as staff members.
The project has shown that it is possible to motivate and enhance the capacity of male multipurpose
workers as a preparatory step for working with men in the community. Within the Indian context, this is
an important model for other initiatives, which have found it difficult to involve the male multipurpose worker.
•
Working at mutually synergistic multiple projects seems to be an important strategy as well. Diverse
inputs are needed to make even a small initiative function well, and WCHP’s investment on multiple
fronts, from capacity building and quality assurance to research and IEC seems to have paid off.
I
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| Women Centred Health Project I Report of the End Evaluation
•
Another lesson learnt is regarding the usefulness of working at various levels of care and of health
providers simultaneously. While focusing on the primary care level, WCHP has also intervened at the
maternity centre and general hospital level so that patients get good quality care all the way up the
chain. The project has also worked with all levels of health providers, from the outreach workers to the
medical officers and MOH and consultant gynaecologists. It has responded to their diverse needs for
training and motivation and won their support for and commitment to the goals of making good quality
reproductive health services available to low-income women.
•
There is still a long way to go before a gender and rights perspective will be institutionalised within the
MCGM’s health care delivery system. Support from the senior decision-makers for the project goals
appears elusive - sometimes present, and sometimes not, given who is at the top and what their
exposure to these issues are. The difficulty in winning bureaucratic support for mainstreaming gender
and rights has been observed in other contexts as well. According to one observation, this is because
they do not see any tangible benefits from this resource-intensive effort.3 This has resulted in “highly
visible, top-down activities such as producing policies, guidelines and data sets rather than on the
slower and more invisible processes of transforming organisational culture and practice at all levels".
WCHP has opted to take the difficult bottom-up option, which has definitely contributed to changing
the thinking of a significant number of health providers.
Larger questions still remain. Even if the project activities sustained and upscale by MCGM, to what
extent will the gains made in terms of perspective change be sustained? How can we prevent this initiative
becoming another medical intervention which no doubt increases access to and availability of reproductive
health services but does not do so from a gender and rights perspective?
Social change, and especially a change in entrenched institutional norms and practices is a protracted
and long-term process that will require ongoing support and monitoring by those who have initiated the
project, or at least those who share the same vision as the initiators of the project. There is no option but
to stay engaged and provide inputs over a very long period, even after the project ceases to exist in its
present form.
A more immediate challenge is the changing context of state involvement in health care services. Public
investment in health is dwindling and private sector participation is being systematically promoted. There
is an urgent need for those concerned with promoting gender and rights perspective in health to come to
grips with the new issues that this throws up. For example, the issue of ensuring that essential reproductive
health services continue to be publicly funded, even if they are provided by the private sector; of lobbying
for state regulation and monitoring of the gender and rights dimensions and ethics private sector provision
of reproductive health services; of working with professional associations of Obstetricians and
Gynaecologists to institute accountability and so on. There is a long haul ahead yet.
3 Nuket Kardam, in ‘Development and Gender in brief: issue 5, ‘Approaches to institutionalising gender’, www.ids.ac.uk/
bridge/dgbS.html referred to on 24 October 2003.
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Annex 1: Schedule of Activities during 10-15 August 2003
10 August, 2003
Arrival in Mumbai and preliminary discussions with Dr Ubale, Renu
Khanna and Korrie de Koning
11 August: Forenoon
Afternoon
Meeting with WCHP staff Visit to gynaecology OPD at SV Nagar
health post, Discussion with CHVs, medical officer at the dispensary.
Meeting with Key RCH trainers: Dr Prabhu and Dr Mahinkar
Meeting with MPWs and CDOs
Meetings with WCHP staff: Praveena (Male involvement programme)
and Anagha (research)
12 August: Forenoon
Visit to counselling booth at the VN Desai Hospital
Meeting with Swati (supervisor), Bharati and Asha (counsellors) about
the booth, Meeting with houseman attending the ORD, Dr Rane, honorary
gynaecologist at the hospital, Dr Aditi Parmar, also consultant
gyanecologist assisting Dr Rane
Observation of a counselling session at the booth
Meeting with Dr Khandare from Colaba ‘A’ ward
Afternoon
Meeting with Dr Kumta, consultant gynaecologist
With a maternity home who monitors the quality of services at the
gynaecology OPDs in one ward Meeting with Mrs Shetty, ANM working
in the VN Desai hospital’s health post.
Meeting with Dr Hargoli, MOH.
Meeting with Vidya, IEC officer of WCHP
13 August: Forenoon
Meeting and discussion with Sneha, WCHP staff member responsible
for the gynaecology OPDs
Visit to gynaecology OPD at Taadwadi
Meetings with FTMO, lab technician, ANM CHVs and one client
Afternoon
Visit to gynaecology OPD at Welkarwadi
Meetings with CHVs and MPW, clients, social worker from the community
Writing up a presentation for meeting with senior MCGM officials on the
following day
Discussions with Renu Khanna
14 August: Forenoon
Meeting with senior officials of MCGM
Presentation of preliminary findings to MCGM officials
Discussion
Afternoon
Touching base with Korrie de Koning and Renu Khanna on overall findings
and impressions
15 August:
Meeting with WCHP staff and detailed debrief
16 August:
Departure from Mumbai
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| Women Centred Health Project I Report of the End Evaluation
Annex 2: A list of all training conducted during project period
(Please refer to box 8.1 in Chapter 8)
Annex 3: The Patients’ rights charter
Draft (Not to be quoted)
Proposed Patients’ Charter for Health Care Services of the BMC
Patients’Rights
1.
Right to information about the health services and make best use of them
2.
Right to information about preventive and curative medicine, after care and good health.
3.
Right to health services free of corruption and political interference.
4.
Right to basic health care, expensive life saving treatment and emergency services at hospitals
irrespective of ability to pay.
5.
Right to easy access to adequate and appropriate health services that are effective and sensitive to
community’s needs.
6.
Right to expect prompt treatment within available resources in an emergency irrespective of client’s
ability to pay, during working hours of the primary and secondary health care facilities and at all times
in casualty departments of secondary and tertiary hospitals.
7.
Right to access to appropriate redressal procedures.
8.
Right to health system that anticipates major health hazards, takes appropriate actions to prevent
those and in unfortunate instances is fully equipped to act effectively to control the damage caused
by health disasters.
9.
Right to be referred to hospital / consultant wherever applicable as per the referral protocols.
10. Right to be transferred to another health care establishment only after an explanation of the need for
transfer and after the other establishment has accepted the patient.
11. Right to seek second opinion about his / her disease, treatment etc. (?? For BMC from teaching
hospitals * (This was not fully accepted in the earlier meetings)
12. Right to polite behaviour and considerate care.
13. Right to refuse to participate in human experimentation, research projects affecting his / her care or
treatment.
14. Right to information on causes, diagnosis, treatment, medicines and preventive measures for a particular
condition.
15. Right to information about expected outcomes, side effects, after effects, chances of success, cost
and availability of prescribed medication.
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16. Right to obtain all the relevant information about the professionals involved in the patient care for
example availability / timing.
17. Right to know what hospital rules and regulations apply to him /her as patient and the facilities
obtainable to the patient (applicable to primary facilities — in terms of user fees, referral, etc.).
18. Right to get the details of the bill (receipts for amounts paid at BMC health care facilities).
19. Right to benefit from advances in medical sciences related to his / her case.
20. Right to expect that all communication and records pertaining to his / her care be treated as confidential.
21. Right to every consideration of his / her privacy concerning his / her medical care programme.
22. Right to have all identifying information, results of investigations, details of his / her condition including
copies of medical records and treatment kept confidential and not made available to anyone else
without his / her consent.
23. Right to clear, concise explanation in lay terms of proposed procedures and available alternatives.
Wherever applicable the explanation should include information on risks, side effects or after effects,
problems relating to recuperation, likelihood of success, and risk of death. Informed consent must be
obtained prior to the conduct of treatment or a procedure. In case of a minor, consent must be
obtained from the parent or guardian. If a patient is incapacitated or any delay would be dangerous,
the doctor is entitled to carry out the procedure after a second opinion is obtained.
24. Right to explicit, informed consent for participation in scientific experimentation (applicable only for
hospitals and maternity homes — review and revise existing format)
25. Information may be withheld from patients in cases where there is good reason to believe that this
might affect patients’ health adversely, however, information must be given to a responsible relative.
(The Group would like to seek legal opinion on this issue.)
26. Right to standard treatment from public health care services / providers.
27. All drugs dispensed shall be of acceptable standards in terms of quality, efficacy, and safety.
28. All medications shall be labeled and include pharmacological name of the medicine
29. Right to legal advice within the jurisdiction of Mumbai regards any malpractice by the hospital, hospital
staff or other health professional.
30. Right to humane terminal care and to die in dignity.
Compiled from:
Pondicherry Declaration on Health Rights and Responsibilities
Manual of Patient’s by a cash
People’s health Charter for Gujarat
Final Draft of People’s Health Charter
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Patients’Responsibilities
1.
To provide accurate and complete information about his / her own health that is required by the
health provider.
2.
To punctually attend the clinics / hospital / dispensary for treatment at given time.
3.
To faithfully undergo the mutually agreed therapy.
4.
To follow the doctors’ instructions diligently.
5.
To preserve all records for one’s illness.
6.
To accept all consequences for one’s informed decisions.
7.
To take the necessary preventive measures in case of infectious diseases as per the doctor’s
instructions.
8.
To make the payment for treatment, wherever applicable, to the doctors / hospitals promptly.
9.
To respect and accept decisions of the doctors .
10. To keep the doctor informed if patient wants to change the doctor or line of treatment or change to
other system of healing.
11. To know and understand “Patients’ rights” and to exercise those responsibly and reasonably.
12. To know and understand purpose and cost of any proposed investigation / procedure / treatment
before deciding to accept it.
13. To treat doctors and nurses with respect.
14. To be aware that doctors, nurses and paramedical staff are also human beings and need respite.
Compiled from:
Pondicherry Declaration on Health Rights and Responsibilities
Manual of Patient’s by a cash
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Annex 4: A list of all research studies carried out during the
project period (kindly please include)
Details of various research studies carried out by the Project
Sr. No. Month/Year Study
£
Objectives
BACKGROUND STUDIES___________________
April 96 -
Waiting time at teaching hospital • To document waiting time at different levels of health
March 97
and maternity homes________
2.
1996
Social analysis for selection of • To identify representative health posts from two
Project wards for conducting focus group discussions
health posts
3.
1996
• Interviews with men from the • To explore the health care needs and health seeking
1.
care facilities______________________________
behaviour
community]
• Interviews with women from • To explore perceptions about health posts
the community
• Interviews with adolescent
boys from the community
• Interviews with adolescent
girls from the community
4.
1996
• To explore providers’ perception of quality of care
Interviews with staff from
health posts (H/E)___________
2.
BASELINE STUDIES_______________________
5.
April - Dece Review of health care facilities
• To document quantitative information about
infrastructure available to the health posts,
mber 1997
dispensaries and maternity homes____________
6.
care
providers’ • To understand the providers’ perception of and
November-
Health
December
perceptions on health care
1997
services70 health providers —
medical,
paramedical
attitude towards women’s health and related issues
and
community health volunteers —
from four dispensaries, four
health posts, two PPCs, one
maternity home and one gene-ral
hospital from Project area_____
7.
April - Dece Client satisfaction study through • To find out the users’ awareness about the health
services provided by various health facilities of the
mber 1997 exit interviews402 users of the
BMC
OPD health services provided by
the dispensaries, health posts, • To document costs incurred by clients on availing
the services
•
To explore whether clients were satisfied by the
General Hospital were interviewed
services and to elicit suggestions for improvement
within the premises of these
PPCs, Urban Health Centre and
facilities and another 40 users of
in the services.
the health post out reach services
were interviewed in their homes
by the trained investigators.____
3.
8.
PILOT INTERVENTIONS FOR QUALITY ASSURANCE
Action Research for Improving • To improve referral systems by ensuring optimum
February
1998 - May
1999
the Referral System
utilisation of the three tiered health care system and
• To establish a feedback system to build links
between different levels of the health care system
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| Women Centred Health Project I Report of the End Evaluation
Sr. No.
Month / Year
Study
9.
March 1998
Monitoring of client-provider
Objectives____________________
• To explore feasibility of monitoring and improving
________________
communication of all cadres of providers using
communication
observation checklist
• To explore possibility of developing mechanisms
for regular monitoring of client- provider communication within the Public Health Care system
10.
April - August
Drugs monitoring study: An
1998
action
research
• To develop a tool to monitor availability of drugs to
clients at dispensaries.
study
designed to serve dual
• To examine whether the tool developed was
purpose of monitoring drug
effective in monitoring distribution of drugs to the
supply to clients and as an
patients.
intervention for improvement
in supply of drugs._________
FALLOUT OF THE PILOT INTERVENTIONS FOR QA
Drugs availability study at • To document the extent of inadequacy of drugs
January - May
ll.
4.
1999
gynaecology
OPD
of
secondary hospital________
12.
1999
13.
Exploratory study of indenting
• To study the indenting and procurement system
and procurement procedure
for drugs in the BMC in order to gain better under-
of BMC__________________
Monitoring client-provider
• To identify factors affecting client-provider
standing into non-availability of drugs to clients
communication
communication at gynaecology
14.
OPD of a secondary hospital
• To explore unmet information needs of clients
Pharmacist study
• To document time allocation over routine activities
of the pharmacists
• To explore feasibility of using modified checklist
for monitoring drugs availability to clients
MEN’S INVOLVEMENT
In-depth interviews with ANMs
1998
15.
—5
5.
• To understand the work pattern
• To explore ANMs’ views about men’s involvement
in women’s health
• To find out problems with men’s involvement
• To obtain suggestions regarding strategies for
involving men
• To understand women’s attitude towards family
16.
17.
18.
19.
1998
In-depth interviews with CHVs
March to
—5
planning_______________________________
• To understand work pattern of CHVs and to find
out if they communicated with men in the
September
In-depth interviews with
community_______________________________
• To find out opportunities where the workers meet
1998
MPWs — 8 interviews______
men during the course of their work _________
June 1998,
Protocol for study on men’s
• To understand nature and extent of husbands’
October
involvement in women’s
involvement in health seeking and women’s
1999,March
health
expectations from their husbands in terms pf
2000
November -
Study on understanding
support during illness______________________
• To find out difficulties / obstacles faced by the men
December
barriers in men’s involvement
accompanying women to the out patient clinic of
2000
in women’s health: 40 men
and 3 health care providers
the hospital
• To explore health care providers’ views about
involving men in women’s health
were interviewed
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Sr. No. | Month/Year
6.
20.
Study
Objectives
COUNSELLING AND INFORMATION BOOTH
2001
Exercise for validation of exit
• To explore possibility of use of exit interviews in
interviews as tool for gathe
place of observations for documenting client
ring information on client
provider communication.
provider communication with
observation technique
21
Baseline for counseling
2001
booth at VND hospital
• To document client provider communication at the
gynaecology OPD
• To identify need for counseling________________
22.
2002 - 2003
Assessing impact of the
• To document impact of the counseling and
counseling booth at the
information booth on style of communication of the
gynaecology OPD
providers and information to the clients
7? GYNAECOLOGY CLINICS AT HEALTH POSTS
23.
2000
and
July 2003
Exit interviews at gynaecology
clinics at health posts
• To explore areas that need to be strengthened for
sustainability of the clinics
• To identify the strategies for mainstreaming the
clinics
• To explore the implications for the implementation
of Urban RCH programme
DEVELOPMENT OF IEC
Study of media preferences by
1998 - 1999
24
men and women from the
8.
• To document media preferences of men and
women in reference to health information
community______________
25.
December
Review of IEC material
• To review existing IEC material
• To collect information about usefulness of IEC
1998
material
• To study the process of distribution from the IEC
Cell to the concerned health setups
• To study the pattern of storage and dissemination
of the material in hospitals and field areas.
• To identify IEC material used by each type of health
care facilities______________________________
26.
March to
Focus group discussions
• To explore awareness about the BMC health
August 1999
with men (4) and women (6)
services — especially health posts and health care
providers
• To understand information needs
• To enable IEC Core Committee members to realise
the importance of incorporating peoples’ perception
while preparing IEC material
EVALUATIVESTUDIES
Pilot study PID ANMs- 5
1998
27.
• To find out from the PID ANMs the changes that
WCHP ANMs - 3Control
have taken place in their perceptions regarding
9.
ANMs-5
women's health
• To find out what new knowledge they have gained
through the training given to them
• To find out what new skills they developed as a
result of the training
• To find out from the PID ANMs any personal
changes experienced by them.
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| Women Centred Health Project I Report of the End Evaluation
Sr. No. Month / Year
Objectives___________________________ _____
Study
• To find out from other health post staff who are
presently working with these PID ANMs, their
perceptions of PIP ANMs.___________________
28.
July 1999
Midterm evaluation of the • To assess the effectiveness of training inputs
provided by the Project
Project
• To explore health care providers’ opinions about
various test interventions introduced by the Project
in order to assess feasibility of mainstreaming the
interventions
• To document change in perspective, and attitudes
of key trainers and members of committees
established by the Project___________________
29.
2000
Evaluation of ANMs trained • To find out from ANMs the changes that have taken
place in their perceptions regarding women’s
during the PID Project, WCHP
and
ANMs from control
health.
areas(PID = 15, WCHP =12, • To find out what new knowledge ANMs have gained
Control = 15)
through the training given to them.
• To find out the skills ANMs have developed as a
result of the trainings.
• to find out from the ANMs, the personal changes
experienced by them._______________________
30.
April to August End evaluation of the Project
• To assess the impact of interventions by the Project
2003
• To explore feasibility of mainstreaming these
interventions in the Public Health Department of
MCGM
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| Women Centred Health Project I Report of the End Evaluation
Annexure 1
______
Table 1 A: Physical structure of health posts included in the baseline study
Physical structure
Health Posts
Type of population
1
2
3
4
5
6
7
8
9
10
11
12
MIX
SLM
MIX
MIX
MIX
MIX
SLM
SLM
MIX
SLM
SLM
SLM
No
No
No
No
No
Yes
No
No
Yes
No
Yes
1991 1990
1990
1985
1992 1991
1984
Independent (stand
alone)_____________
Yes
Year of establishment 1992
1985
1992 1991
Ownership of building M3GM MCGM M3GM MCGM MuGM MCGM MCGM MCGM MCGM MCGM MCGM MCGM
Compound wall_____ Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Floor space (sq. ft.)
864
700
700
144
720 300
950
460
410
225
100
500
1984
No. of rooms
3
3
1
4
1
2
2
2
2
4
1
1
Rest room for staff
No
No
No
No
No
No
No
No
No
No
No
No
meeting___________
No
No
No
No
No
No
No
No
No
No
No
No
No. of toilets attached
2
2
NA
1
1
1
2
1
Separate room for
1
Toilets cleaned daily
Water supply (24
hours)_____________
No
Yes
NA
Yes
No
Yes
NA
Yes
NA
NA
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Electricity available
Yes
Yes
No
No
Yes
room______________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Examination room
Yes
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
No
(sq.ft)_____________
Disposal of wastes
96
80
, NA
NA
NA
120
NA
NA
NO
50
NA
GB
GB
GB
GB
GB
GB
GB
GB
GB
100
GB
GB
GB
Separate storage place
No
No
Yes
No
No
No
No
No
Yes
Yes
No
No
Separate Examination
Note : Codes were assigned to health posts in order to maintain anonymity
MIX- slum and non slum population
GB garbage bin
SLM - slum population
NA - not applicable
- Nil
Table 1B: Physical structure of dispensaries included in the baseline study
DISPENSARIES
Physical Structure__
1
2
3
4
5
6
7
8
9
MIX
MIX
SLM
SLM
SLM
SLM
SLM
Yes
No
Yes
1972
1970
NK
Independent ( stand alone )
MIX
MIX
Year of establishment________
No
No
No
Yes
Yes
No
Ownership of building
1990
NK
1979
1971
NK
1977
Compound wall______________ MCGM
MCGM MCGM
MCGM
MCGM
Floor space (sq. ft.)___________
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No. of rooms_______________
Rest room for staff
2500
Yes
1500
1000
4000
144
225
500
1120
500
9
6
9
11
2
2
6
8
5
Separate room for staff meeting
No
No
No
No
No
No
No
No
No
No. of toilets________________
Toilets cleaned daily
2
Yes
2
Yes
3
No
2
Yes
2
Yes
1
Yes
2
NK
3
No
2
No
MCGM MCGM MCGM MCGM
Separate toilet for staff________
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Water supply regular
Yes
Yes
No
Yes
No
No
No
No
No
Electricity available
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Separate Examination room
Yes
Yes
Yes
Yes
No
No
Yes
No
No
Examination Area in (sq. ft)
300
144
125
150
NA
NA
150
NA
NA
Disposal of wastes___________
GB
GB
GB
GB
GB
GB
GB
GB
GB
Separate storage place
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
184
I Women Centred Health Project I Report of the End Evaluation
Table 1C: Physical structure of post partum centres included in the baseline study
POST PARTUM CENTRES
PHYSICAL NVIRONMENT
1
2
Type of population
MIX
MIX
Independent ( stand allone )
No
No
Year of establishment
1992
1992
Floor space (sq. ft.)
350
300
No. of rooms
3
2
Rest room for staff
No
No
Separate room for meeting
No
No
No. of toilets
1
1
Toilets cleaned daily
No
Yes
Separate toilet for staff
Yes
No
Regular water supply
Yes
Yes
Electricity available
Yes
Yes
Examination room
No
No
Disposal of wastes
GB
GB
Separate storage place
No
Yes
Note : Codes were assigned to health posts in order to maintain anonymity
MIX- slum and non slum population
SLM - slum population
. Nil
NA - not applicable
GB garbage bin
Table 2A: Services provided by health posts included in the baseline study
Health Posts
Services available
1
2
z
z"
z
z
Out patient day
Immunisation
Family planning
Treatment for TB
~7
z
z
z
z
z
T
4
3
7
6
9
8
10
11
12
z
z
z"
z
z
z
z
"z
z
z
z
z
z
z
z
z
Disease surveillance
Cleanliness duty
Post natal care
Well baby clinic
z
I EC. activity_________
Total Services
5
6
5
z
z
z
z
z
8
7
Note : IEC - Information Education and Communication
z
z
z
z
Antenatal care
5
6
z
z
5
4
z
z
5
7
3
- = Not available
z = Available
Table 2B: Services provided by dispensaries included in the baseline study
Services
Total
Dispensaries
1
2
5
Z
4
3
General Health checkup
6
7
8
Z
9
9
z
Immunisation
6
z
z
z
Tuberculosis treatment
Dental
2
z
z
Family planning
3
z
Laboratory
2
z
z
Malaria smear
4
1
Sputum examination
z
I.E.C. activity___________
Total services
5
1
4
Note : IEC - Information Education and Communication
3
6
5
z = Available
185
1
4
2
3
- = Not available
z
£
3
9
| Women ( cntred Health Project I Report of the End Evaluation
Table 2C: Services provided by Post Partum Centres included in the baseline study
Services
Post Partum Centres
—1
£
Total
Well Women Clinic
Z
1
Antenatal Care Check Up
1
Post Natal Care ( OPD)
1
Paediatric OPD
Z
2
2
Spacing Contraceptive Method
Z
Sonography
I.E.C.Activity_______________
z
z
z
z
2
Total number of services
6
5
11
Blood Investigations
1
1
_________ Table 3A: Human resource at health posts included in the baseline study
Categories of staff
Health Posts
(As per IPP-V norm) 1
2
3
4
5___
6
1
8
9
11
10
F.T.M.O. (1/1)
1
1
1
1
1
1
1
1
1
PH N
1
1
1
1
1
1
1
1
1
1
1
(1/1)
AN M
5
4
2
2
4
3
(4/5)
5
1
2
1
3
MPW
4
2
1
2
3
1
3
2
1
(4/3)
1
1
Clerk
1
1
1
1
1
1
1
1
(1/1)
1 ’
2
1
1
1
Ayabai
1
1
1
1
1
1
(1/1)
22
10
25
CH V
(25/40)
17 25
13
12
8
3
22
25
3
10 20
Locality CHV
8
3
22
25
FFW Ml
Additional staff
TO TO
TO
TO
Cord
& Cord
Cord
12
1
1
4
1
1
10
7
Table 3B: Human resource at dispensaries included in the baseline study
Category of staff &
the norm
M.O.
Dispensaries
2
2
3
(1/1)
1
1
1
PHARMACIST
(1/1)
1
1
1
DRESSER
(1/1)
1
1
1
I/C
ATTENDENT
(1/1)
1
1
SWEEPER
(1/1)
ADDITIONAL STAFF
Note :
4
DET= Dentist
Ml = Malaria Investigator
6^
FFW
7
2
Total/ Norm
1
1
1
1
1
8/9
1
1
1
1
1
1
9/9
1
1
1
1
1
1
9/9
1
1
1
1
1
7/9
1
1
TO
TO
TO
<
&MI
1
1
DET
£
4/9
TO
TO
<
FFW= Female Field Worker
TO= Treatment Organiser for Tuberculosis
LT= Laboratory Technician
Table 3C: Human resource at Post Partum Centres included in the baseline study
CATEGORY OF STAFF
POST PARTUM CENTRES
NORM
2
2______
1
1
2
Medical Officer I (Gynaecology)
1
1
Medical Officer II (Paediatrics)
1
Auxiliary Nurse Midwife
1
2
Multipurpose worker
1
1
Clerk
1
1
1
Note : - = Vacant post
186
1
| Women Centred Health Project I Report of the End Evaluation
Table 4A: Gender and qualification of staff at health posts included in baseline study
Catetory of Staff
1. Doctor
Number of Qualification of the staff
Sex Composition
Health posts
Male
Female
5
5
0
12
0
12
9
2
8
2
2
2
0
12
3
0
0
1
10
9
1
11
7
7
3
11
1
7
3
2
2
2
2
8
2
1
1
M.B.B.S.
M.D.
12
2. Public Health Nurse (PHN)
General Nursing
Midwife Nursing
10
3. Auxilliary Nurse Midwife (ANM)
General Nursing
MN/GN
12
4. Multi Purpose Worker (MPW)
Sanitary Inspector Course
Graduate
10
5. Clerk
S. S.C.
Graduate
4
6. Treatment Organiser (TO)
T. O. training
Graduate
12
7. Attendant
S.S.C.
< Middle School
Non literate
3
8. Coordinator
Sanitary Inspector Course
S.S.C.
1
9. Female Field Worker (FFW)
Midwife Nursing
Table 4B: Gender and qualification of staff at dispensaries included in baseline study
Sex Composition
Qualification
No. of
Category of Staff
Male
Dispensaries
1. Doctor
2. Pharmacist
3. Dresser
4. Attendant
9
9
9
7
M.B.B.S.
Diploma Phamacy
S. S.C.
Upto Std. 4
S.S.C.
Upto Std. 9
Non-literate
5. Pathologist
6. Treatment Organiser
7. Sweeper
8. Malaria Inspector
9. Laboratory Technician
1
5
3
2
1
BSC/MLT
S.S.C.
Non literate
S.S.C.
M.S.C. DLT
187
I
9
9
6
3
2
3
2
1
5
3
2
1
Female
7
3
2
9
0
7
0
4
1
1
0
0
1
1
2
1
1
6
| Women Centred Health Project I Report of the End Evaluation
Table 5A: Utilisation of services provided by health posts included in the baseline
Services / Health Posts) 1
|2
|3
|4
| 5
|6
|7
10
11 12
8
9
Number of cases followed-up by the health post staff*
Family Planning
Immunization
Antenatal Care
Water Borne Diseases
525
267
118
000
353
382
160
048
128
501
098
002
171
317
102
003
2704
2859
0124
0000
165
291
050
023
025
317
049
025
543
685
073
000
05
29
07
02
2134 06
2844 89
0245 52
0003 16
88
85
22
22
000
011
000
010'
000
137
002
034
0000 000
0003 010
002
021
000
008
01
06
0000 00
0003 00
00
00
Vaccine Preventable
Diseases
Others
Persons availing different type of services from the health posts covered In the study area*
Immunization at health
post
Immunization (Camp)
Out Patient Day
Home Visits
I EC Activity
36
18
11
1373
11
35
60
211
960
405
300
66
104
36
13
846
900
3
NK
NK
NK
NK
NK
114
144
21
128
360
23
56 60
117 15
AAA
28
1015 643 1440
34
438
2
Note: *The data refers to the week proceeding data collection.
*** = film shows once a month AAA = Doctor not available
NK = Not Known
Table 5B: Utilisation of services provided by the dispensaries included in the baseline
Dispensary
Services
2
3
545 299
1
Immunisation at the dispensary
OPD
3
4
86
426
794
6
7
8
9
426
615
441 545
Total
3
4177
Note: This data pertains to the number of persons using the health care services in the week proceeding the data
collection.
Table 5C: Utilisation of services provided by the Post Partum Centres included in the baseline
POST PARTUM CENTRE
SERVICES
2
1
OPD
301
I EC activities
563
Note: This data pertains to the number of persons using the health care services in the week proceeding the data
collection.
I
188
1
| Women Centred Health Project I Report of the End Evaluation
Table 6A: Registers maintained by the health posts in the baseline study
Name of the register
H/East
G/North
(n=6)
(n=6)
Name of the register
H/East
G/North
(n=6)
(n=6)
1.
Baseline
6
6
28. Health Talk
5
6
2.
Birth and Death
5
6
29. Cleanliness Programme
6
6
3.
Eligible Couple
6
6
30. Incentive book
2
4
4V
Family Planning
5
6
31. Referral Book
6
3
5.
Nirodh (Stock Reg.)
5
6
32. Steriliser Book
6
5
6.
Oral Pills (Stock Reg.)
5
6
33. Syringes book
6
6
6
6
7.
Copper T insertion
5
6
34. Temperature Chart
8.
Copper T removal
6
4
35. Review Register
5
5
6
9.
Sterilisation
10. Successful motivation
6
6
36. Stock Register
6
5
5
37. Output - Dispatch
6
6
3
11. Child Register
6
6
38. Injection Register
12. Immunisation (Area)
6
6
39. Tablet Register
5
5
4
6
5
13. Immunisation (HP)
6
5
40. I EC stock book
14. Disease Surveillance
• 6
6
41. Indent Book
6
5
6
6
15. VPD Register
6
6
42. Dead Stock Register
16. ORS Register
6
6
43. Stationary Book
6
5
5
17. Vitamin A
6
4
44. Impress book
6
18. Immunisation Report
6
6
45. Programme Book
6
6
6
19. Vaccine report book
6
6
46. Visit Book
5
20. Acute resp. register
3
2
47. Daily Diary
6
6
6
6
21. Complication Register
6
6
48. Monthly Report
22. ANC Camp
4
5
49. Daily Report Book
6
6
5
23; PNC
24. ANC/PNC fl
5
4
50. Cross Check file
5
6
6
51. CHV report
6
6
6
5
25. Pana M
6
5
52. PMP Report
26. Pana C
6
5
53. Circular file
6
5
4
54. Concession Register
5
4
27. R 15 R 16
5
Table 6B: registers maintained at dispensaries included in the baseline study
Name of the register
H/East
G/North
(n=6)
(n=6)
Name of the register
H/East
G/North
(n=6)
(n=6)
13. Output - Dispatch
4
3
1.
Nirodh (Stock Reg.)
1
2.
Sterilisation
2
3
14. Injection Register
2
2
3.
Immunisation (HP)
1
1
15. Tablet Register
3
2
4.
Disease Surveillance
4
5
16. Indent Book
4
2
17. Dead Stock Register
4
4
5.
ORS Register
1
6.
Immunisation Report
3
7.
8.
9.
4
18. Stationary Book
1
3
4
Vaccine report book
2
2
19. Impress book
4
Complication Register
4
5
20. Visit Book
4
3
4
4
2
1
Steriliser Book
2
2
21. Monthly Report
10. Syringes book
1
1
22. Daily Report Book
1
11. Temperature Chart
4
5
23. Circular file
4
12. Stock Register
4
4
24. Concession Register
1
189
1
j Women Centred Health Project""] Report of the End Evaluation
Table 6C: Registers maintained at post partum centres included in the baseline study
Name of the register
H/East
G/North
Name of the register
1.
Family Planning
1
17. Cleanliness Programme
2.
Nirodh (Stock Reg.)
1
18. Incentive book
3.
Oral Pills (Stock Reg.)
4.
Copper T insertion
1
1
’
1
19. Referral Book
1
20. Stock Register
5.
Copper T removal
1
21. Output - Dispatch
6.
Sterilisation
1
22. Tablet Register
G/North
H/East
1
1
1
1
1
1
1
7.
Successful motivation
1
23. Indent Book
8.
Child Register
1
24. Dead Stock Register
9.
ORS Register
1
25. Stationary Book
1
26. Impress book
1
1
27. Programme Book
1
28. Visit Book
1
1
1
1
10. Acute resp. register
11. Complication Register
12. ANC/PNC fl
13. Pana M
1
29. Daily Diary
14. Pana C
1
30. Monthly Report
15. R 15 R 16
16. Health Talk
1
1
1
1
1
1
1
31. Circular file
1
32. Concession Register
1
Note : - = not maintained in the RPC
Table 7A: Equipment available at health posts included in the baseline study
Equipments
H/East
G/North
Equipments
H/East
G/North
(n=6)
(n=6)
4
4
(n=6)
(n=6)
Stethoscope
5
4
11.
2.
B.P.apparatus
3
5
12. Steriliser
3
5
3.
Tongue Depressor.
3
4
13. Autoclave
2
2
4.
Thermometer
1
3
14. Cooker
5
5
5.
Hammer
4
3
15. Vaccine Carriers
5
5
6.
Torch
4
5
16. Speculum
4
1
7.
Measuring Tape
1
1
17. Vulselum
4
1
1
0
1.
Dial Thermometer
8.
Weighing Scale (Adult)
6
3
18. Vaginal Wall Retractor
4
9.
Weight Scale (Child)
6
5
19. Ovarian Sound
3
5
5
10. Refrigerators
Table 7B: Equipment available at dispensaries included in the baseline study
Equipments
H/East
G/North
(n=4)
(n=5)
Equipments
H/East
G/North
(n=4)
(n=5)
1.
Stethoscope
4
4
11.
Refrigerators
4
3
2.
B.P.apparatus
4
4
12. Dial Thermometer
3
4
3
4
3.
Tongue Depressor
1
3
13. Steriliser
4.
Thermometer
4
2
14. Autoclave
5.
Hammer
2
3
15. Cooker
4
4
6.
Torch
4
3
16. Vaccine Carriers
4
5
7.
Measuring Tape
1
17. Speculum
1
8.
Weighing Scale (Adult)
4
18. Vulselum
1
1
19. Vaginal Wall Retractor
9.
Weight Scale (Child)
1
1
20. Ovarian Sound
10. Foetoscope
I
190
| Women Centred Health Project 1 Report of the End Evaluation
Table 7C: Equipment available at post partum centres included in the baseline study
Name of the items
PPC1
PPC2
Name of the items
PPC1
PPC2
1.Mobile Examination LAMP
1
3(1
given
34. B.P apparatus
6
2(1
given to
KMH)
to KMH)
2. Bowl
3. Kidney Tray
4.
Fumigator
26
8
35. Surgical Dressing Drums
4
4*
12
2
36. Instrument Sterilizer
2
1
1
1*
37. Suction Apparatus
1
1*
5.
U V Tubelight
1
1*
6.
Uterine Manipulator
2
7
38. Autoclave
1
7.
Stethoscope (child & adult)
9
3(2
39. Photo Theraphy Unit
1
r
r
given
40. Ambu Bag and Mask
1
2*
to KMH)
41. Oxygen-Hood Size 6”X 6”X 6”
2
2*
(suction pump )
8.
Tuning Fork
1
1
42. Laryngoscope (paediatric)
1
9.
Uterine Sound
7
2*
43. Personal Weighing Scale
1
1
10. Vulsellum Forceps
• 4
8
44. Centrifuge Machine
1
1
32 (30
45. Laboratory Incubator
1
1
given
46. Binocular Microscope
1
1
to KMH)
47. Radiant Heat Warmer
1
8(7
48. Mobile Shadowless Lamp
1
given to
49. Nebulizer / Pulmo - aids
1
KMH)
50. Serological Water Bath
1
1
10 (4
51. VDRL Shaker ideal
1
1
given
52. Instrument Sterilizer
1
to KMH)
53. Semi auto Analyser
1
2*
54. Calposcope
1
1
1
1
11. Artery Forceps
12. Tooth Forceps 6”
13. Anterior Vaginal Wall
36
10
2
Retractor
14. Cheatles Forceps
2
1*
1
15. Ovum Forceps
2
2*
55. Ambu Bag and Mask (adult)
16. Curetter
12
6
56. Baby Suction Machine
2
1*
8
12*
6
8*
57. Cap utrs 02 Cylinders with Cap 2
2
58. Key Spanner
2
6(4
59. Flow Meter for 02 Cylinder
2
10
17. Allis Forceps
18. Right Angle Retractor
19. Babcock Forceps 8” & 6”
20. Plain Forceps 6”
8
2
given
(6 given
to KHM)
to KMH)
4*
60. Regulators for 02 Cylinder
2
21. Kocher‘s Clamp (curved )
2
2*
61. Inhalor Polymask ( adult & child) 8
22. Mosquito Forceps
1
4*
62. Cidex Trays (CX - 27)
6
1*
63. Torch
2
2‘
23. Cat’s Paw Retractor
10
24. Towel Clip (small & large)
14
64. S. Tray with Cover (paed .wad .) 11
6*
25. Ayre’s Spatula
2
4
65. Baby Weighing Machine (libra) 1
3*
26. Suction Canula
2
22*
66. Diamond Pencil
2
2
67. Sponge Holder
7
7(6
27. Shirodkar loop (removing book) 2
1
28. Tongue Depressor
2
1
given to
KMH)
5(3
29. Sim’s speculum
(small, medium & large)
14
14*
30. Cusco’s Speculum
4
4*
68. Scissor
5
given to
KMH)
(large & medium)
31. Laryngoscope (adult)
1
2*
69. Knee jerk hammer
1
1
32. Set of dialator
2
2*
70. Refrigerator (268 Itr.)
2
1
33. Baby Weighing Machine (Unicef) 1
3
71. Baby Weighing scale (paed.wd.) 1
1
191
1
W omen C e ntred H e al th P roj e c t I Report of the End Evaluation
PPC1
PRC 2
Name of the items
72. Examination table
2
2*
92. Charity Cash Box
1
93. Revolving Stool
2
94. Voltage Stabilizer
1
(with steel folds)
73. units
1
1
PRC 2
PRC 1
Name of the items
1
1 (gone
for
(gone for
repairs)
repair)
K-
1 (gone
1
95. U.S.G Machine
74. Needle Holder
10
10*
75. Steel Cupboard (big size)
7
4
for
76. Bed Sheet Screen (3 folds)
5
5
repairs)
77. Clip board
1
78. KitC
3 box
79. Blanket Woollen (small )
10
80. Patients cot
20
81. Baby cots
0
6*
16*
96. Instrument Cupboard
1
1*
97. V.C.R
1
1
98. Television
1
1
99. Lockers and bed side
8
16*
100. Cradle with stand
2
2*
3
5
1
4
82. Bed Sheets (small)
20
101. Table
83. Draw Sheets
25
102. Television cover with trolley
1
84. Mattresses
6
85. Cushions with covers
6
103. Video cassettes
4
18 (6
104. Urine glass
6
given to
105. Couplick Jars
6
KMH)
106. Glasses
2
2
20*
2
10
86. Medicine Stand
1
1
87. I.V Stand
2
3
107. S. Cups
108. Sputum mug with cover*
88. Bed screen covers
1
5
109. Towel clips
89. Chairs
20
10
110. Anesthetist Trolly
1*
90. Canvas Stretcher
1
1*
111. Oxygen cylinder
5*
91. Cash Box
1
2
112. Stove
1
Note: - not available
Table 8A: Drugs available at health posts included in the baseline study
H/East
(n=4)
4
1. Paracetamol
1
2. Avil
3
3. Chloroquine
1
4. Antacid
1
5. Mebex
1
6. Belladona
4
7. Flagyl
1
8. Doxycycline
1
9. Ampicillin
2
10. Erethromycin
2
11. Terramycine
2
12. Cotrimoxazole
4
13. Vaginal pessaries
2
14. Isoniazide
2
15. Pyrazinamide
2
16. Ethambutol
1
17. Streptomycin
3
18. Iron folic Acid
4
19. Vitamin B Complex
1
20. Vitamin C________
Syrup______________
2
21. Cough
4
22. Paracetamol
Name of the drug
H/East
(n=4)
0
23. Avil
1
24. Flagyl
2
25. Erethromycin
2
26. Ampicillin
1
27. Multi vitamin
3
28. Vitamin A
29. ORS Packet_______ 4
Local Applicant
1
30. Tincture Iodine
1
31. Tincture Benzoin
1
32. Benzy Benzonate
1
33. Soframydn Ointment
Name of the drug
G/North
(n=5)
3
0
0
0
2
1
2
4
1
0
2
3
5
0
0
0
0
4
5
0
G/North
(n=5)
1
3
0
1
0
2
5
1
1
0
0
Vaccines________
34. BCG
35. Polio
36. DPT
37. Measles
38.
39. ____________________
Spacing (FP) metbods
40. Copper T
41. Oral Pills
42. Condom
3
2
Note - not available
I
192
1
5
6
6
6
6
6
6
6
6
6
6
6
6
6
5
5
6
6
v
t Women Centred Health Project I Report of the End Evaluation
Table 8B: Drugs available at dispensaries included in the baseline study
Name of the drug
1. Paracetamol
2. Avil
3. Chloroquine
s
4. Antacid
5. Dulcolax
6. Mebex
7. Belladona
8. Flagyl
9. Doxycycline
10. Ampicillin
11. Erethromycin
12. Terramycine
13. Cotrimoxazole
14. Vaginal pessaries
15. Isoniazide
16. Pyrazinamide
17. Ethambutol
18. Rifampicin
19. Streptomycin
20. Iron folic Acid
21. Calcium
22. Vitamin B Complex
23. Vitamin C
24. Vitamin A and D
25. Multi Vitamin
Syrup
26. Cough
27. Paracetamol
H/East
G/North
(n=4)
2
3
4
4
4
4
2
3
3
2
1
1
2
1
2
(n=5)
5
4
2
2
1
3
3
4
4
3
1
4
3
4
1
1
4
H/East
(n=4)
3
2
2
2
1
28. Avil
29. Flagyl
30. Erethromycin
31. Ampicillin
32. Multi vitamin
33. Vitamin A
34. ORS Packet_____ 1
Local Applicant
3
35. Tincture Iodine
4
36. Tincture Benzoin
4
37. Gentian Violet
3
38. Calamin lotion
2
39. Benzy Benzonate
40. Hydrogen Peroxide 4
41. Soframycin
4
Ointment
42. Turpentine Lininete 4
3
5
5
4
3
5
2
4
3
3
3
2
3
1
3
Name of the drug
G/North
(n=5)
2
2
4
3
1
2
1
5
3
3
3
4
5
1
43. Soframycine Eye/
4
Ear drops
4
44. Chloroapplicap
Vaccines___________
5
5
45. BCG
46. Polio
47. DPT
48. Measles
49.
50.
1
2
1
1
2
3
2
2
3
3
4
Table 8C: Drugs available at post partum centres included in the baseline study
Name of the drug_____
1. Paracetamol
2. Avil
3. Chloroquine
4. Mebex
5. Belladona
6. Flagyl
7. Doxycycline
8. Erethromycin
9. Cotrimoxazole
10. Vaginal pessaries
11. Calcium
12. Vitamin B Complex
G/North
H/East
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Syrup______________
13. Cough
14. Paracetamol
15. Avil
16. Flagyl
17. Erethromycin
18. Ampicillin
19. ORS Packet
1
1
193
1
| Women Centred Health Project I Report of the End Evaluation
Table 9: Profile of health care providers (Providers’ Perception Study)
Sex
n
Health care
provider
Male Female Min.
15 4
11
24
1. Medical office
2. Public health
nurse________ 2
3. Auxiliary Nurse
Midwife______ 10
4. Multipurpose
worker_______ 5 4
5. Community
health volunteer 12
6. Nurse________ 5
4 4
7. Pharmacist
8. Treatment
organiser_____ 1 1
9. Laboratory
2
technician
10. Clerk________ 5 3
2
11. Attendant
12. Dresser_____ 4 4
3 1
13. Labourer
70
21
TOTAL
Total work
experience
(years)
Max.
Min.
Unmarried
Max. Married
30
2
2
54 13
7
18 months 4 years
2
1
18
3 months
11 years
40 3
2
5
20
5 years
7 years
21
34
24
42 11
52 5
39 3
1
1
6m
16
5
30
15
6 months
3 years
2 years
7 years
13 years
11 years
32
32
1
7
7
7 years
7 years
39
25
28
41
40
47
38
40
58
53
6
3
5
20
16
22
19
7
28
27
5 years
3 years
3 years
9 years
3
22 years
9 years
7 years
28 years
10 years
32
38 2
10
22
50 8
1
26
12
5
2
49
Max,
Min._____
11 months 9 years
7
2
2
2
2
Work experience
on present post
Marital status
Age
(years)
2
4
2
4
3
60
1
7
10
Table 10: Educational profile of health care providers (Providers’ Perception Study)
Category of health
care providers
Medical
n=15
officers
Public Health Nurse
n=2_____________
Auxiliary nurse mid
wife n=10________
Multipurpose worker
n=5_____________
Community health
volunteer n=12
Health
post
n=32
MBBS (2)
Post graduate (1)
General
nursing (2)
ANM
training (5)
Sa nitary
inspector (4)
Std. 5-7
(1)Std. 8 10(8)HSC/
Std 12 (1)
Graduate (2)
Nurse n=5
Pharmacist n=4
Treatment orgniser n-1 SSC (1)
Laboratory technician n=2________
SSC (2)
Clerk n=5
HSC (1)
Std. 8-10 (2)
Attendant n-2
Dresser n=4
Labourer n=3
Dispensary
n=17
M B B S
(4)BDS (1)
Maternity
Post Parhome
tum Centre
n=6
n=8
Post Post
graduate graduate (1)
(2)_______
N.M
ANM A
training (3) training (1)
Sanitary
inspector (1)
D. Pharm.
(4)_______
General
nursing (3)
DMLT(1)
DMLT(1)
HSC
(1)
Graduate (1)
Std. 5-7(1)
SSC
(2)
HSC (1)
SSC
(1)
Nonliterate
(2)_______
Total
General
hospital
_____ n=70_____
n=7
MBBS (2) MBBS (8)Post
Postgrad graduate (6) BDS
uate^)
(1) _____________
General nursing
(2) ____________
ANM trai ANM training (10)
ning (1)
Sanitary inspector
(5)____________
Std.5-7(1)Std.8-10
(8)HSC/Std12(1)
Graduate (2)
General
nursing (2)
General nursing
(5)____________
D. Pharm. (4)
SSC (1)________
DMLT(1)
SSC (2)HSC (2)
Graduate (1)
Std.8-10(2)
Std.5-7(1)SSC
(2) HSC (1)
SSC
(1)NonIiterate (2)
194
| Women Centred Health Project I Report of the End Evaluation
Table 11: Perception of providers about ailments commonly reported by women
Health care provider
1
Maternity
Post
Home
Partum
Centre
F__
F
M
n=6 n=—n=6
n=2
2
3
1
5
3
1
2
1
1
2
4
6
1
2
1
2
2
1
Health post Dispensary
M
n=7
1
Minor ailments
2
Weakness
1
Abdominal pain
1
Menstrual problems
Gynaecological problems 5
Family planning
TB
STDs
3
Vaginal discharge
Infertility
1
Sexual problems
F_ M__
n=25 n=11
8
7
3
16
6
8
2
2
16
5
11
1
2
1
19
2
4
F
n=6
1
1
1
1
6
2
4
2
General
Hospital
M
n=1
1
1
1
F
n=6
2
4
3
1
6
2
3
2
Total
M__
n=21
9
6
1
4
11
2
1
2
7
F
n=49
22
35
13
12
32
8
4
1
33
10
1
Note: Multiple response
___________ Table 12: Providers* perceptions of ailments not reported by women
Health care provider
M
n=7
Minor ailments
Weakness
Abdominal pain
Menstrual problems
Gynaecological
problems
Family planning
TB
STDs
Vaginal discharge
Infertility
Sexual problems
Maternity
Post
Partum
Home
Centre
F
M
M
F
n=2
n=6 n= - n=6
2
1
Health post Dispensary
M
F_
£=25 n=11
4
2
1
1
3
1
1
1
1
1
2
10
3
8
8
10
1
2
F__
n=6
1
1
M
n=1
F__
n=6
1
1
2
1
3
1
1
4
6
1
1
1
1
2
3
2
Total
General
Hospital
1
1
3
2
5
1
3
1
3
3
1
1
2
F
M__
n=21 n=49
2
9
1
1
1
4
5
6
2
2
7
1
2
Note: Multiple responses
Table 13 : Perceived reasons for women not reporting ailments
Reason for not reporting ailments
Men
n=19
5
4
9
Non-literacy
Fear of society / Scared to seek help
Feel shy of male doctor
Poverty
Reasons related to health care facilities
No support from family members
Ignorance
Negligence
Self treatment
Lack of privacy
Indian culture
Personal reasons
1
1
0
1
1
1
1
1
195
Health care providers
Total
Women
n=68
n=49
8
3
20
16
32
23
2
2
9
8
10
9
5
5
4
3
2
1
1
1
1
26
3
9
13
19
4
6
i Women Centred Health Project I Report of the End Evaluation
Table 14: Constituents of quality of care: Providers’ perceptions
Constituents of good
quality health care
All services available
Adequate quantity of drugs
Good staff behaviour
Patient satisfaction
Proper examination
Quick services
Good quality medicines
Competent doctors
Others
Health post Dispensary
n=32
8
11
9
5
9
5
1
5
6
n=17
2
6
Post
Partum
Centre
n=8
1
2
3
2
1
5
2
Maternity
Home
General
Hospital
Total
n=6
n=7
3
n=70
13
17
12
16
14
8
3
6
12
1
2
1
2
1
2
1
1
5
Table 15: Suggestions for improvement in quality of health care
Health care provider
Health post Dispensary
n=32
Related to infrastructure
All services should be
4
available
1
24 hour service
2
Investigation facilities
1
Adequate staff
2
Availability of doctor
5
Gynaecological services
Availability of equipment
14
Availability of drugs
3
Availability of lady doctor
1
Paediatric services
Separate examination room
3
Responsibility placed on patients
Health education
5
Create awareness of
services______________
Providers’ responsibility
2
Improve staff behaviour
n=17
1
2
1
3
2
Post
Partum
Centre
n=8
Maternity
Home
General
Hospital
Total
n=6
n=7
n=70
1
1
1
1
1
1
1
1
1
1
2
1
1
7
5
6
4
3
7
3
24
5
2
3
2
2
4
1
1
3
2
1
11
2
1
1
4
1
3
Table 16A: Perception of women’s health — health care providers from Health posts (n=32)
STATEMENT
1. Women suffer more health problems than men.
2. Women are less capable than men to make
decisions in the family
3. Men should take more responsibility for contraceptive use
4. Women have more difficulties than men in protecting
themselves from STDs.
5. Women should be examined by the female doctors only
6. Husband has right to sex with his wife without her wish
7. Women suffer from health problems because they are
ignorant of their own health needs
Disag = Disagree
196
Fully Partly Can’t
Agree Agree say
27
418
25
8
6
21
14
2
7
8
5
2
25
4
2
1
Fully
Disag
1
Partly no res
Disag ponse
5
1
1
1
7
22
2
3
1
1
| Women Centred Health Project I Report of the End Evaluation
Table 16B: Perception of women’s health — health care providers from dispensaries (n=17)
Partly Can’t Fully Partly no res
Fully
STATEMENT
Disag Disag ponse
Agree Agree Say
1
1
2
13
1. Women suffer more health problems than men
2. Women are less capable than men to make decisions in
the family
3. Men should take more responsibility for contraceptive use
4. Women have more difficulties than men in protecting
themselves from STDs.
5. Women should be examined by the female doctors only.
6. Husband has right to sex with his wife without her wish
7. Women suffer from health problems because they are
ignorant of their own health needs
6
14
4
2
2
1
1
9
6
2
3
5
1
4
1
3
1
3
11
11
2
2
2
4
2
Table 16C: Perception of women’s health — health care providers from post partum
_______ centres (n=8)_______ _______ _____
Partly no resFully Partly Can’t Fully
STATEMENT
Disag ponse
Disag
Agree Agree Say
1
7
1. Women suffer more health problems than men
2. Women are less capable than men to make decisions
in the family
3. Men should take more responsibility for contraceptive use
4. Women have more difficulties than men in protecting
themselves from STDs
5. Women should be examined by the female doctors only
6. Husband has right to sex with his wife without her wish
7. Women suffer from health problems because they are
ignorant of their own health needs
5
8
2
4
1
1
2
7
1
1
1
2
5
8
Table 16D: Perception of women’s health — health care providers from maternity homes (n=6)
Partly Can’t Fully Partly no resFully
STATEMENT
Disag Disag ponse
Agree Agree Say
1
5
1. Women suffer more health problems than men.
2. Women are less capable than men to make decisions in
3
2
the family
3
3. Men should take more responsibility for contraceptive use 2
4. Women have more difficulties than men in protecting
5
themselves from STDs
5. Women should be examined by the female doctors only
6. Husband has right to sex with his wife without her wish
7. Women suffer from health problems because they are
3
2
ignorant of their own health needs_________________
1
1
1
2
5
2
1
1
1
1
Table 16E: Perception of women’s health — health care providers from general hospital (n=7)
Partly Can’t Fully Partly no res
Fully
STATEMENT
Disag Disag ponse
Agree Agree Say
1
6
1. Women suffer more health problems than men.
2. Women are less capable than men to make decisions in
1
2
the family
2
5
3. Men should take more responsibility for contraceptive use
4. Women have more difficulties than men in protecting
6
themselves from STDs.
1
5. Women should be examined by the female doctors only
6. Husband has right to sex with his wife without her wish
7. Women suffer from health problems because they are
2
5
ignorant of their own health needs_________________
Disag = Disagree
I
197
1
2
1
1
1
7
1
| Women Centred Health Project I Report of the End Evaluation
Table 16F: Perception of women’s health — health care providers (Total, n=70)
STATEMENT
Fully
Partly
Can’t
Fully
Partly
no
Agree
Agree
Say
Disag
Disag
response
1
2
1. Women suffer more health problems
58
8
than men
2. Women are less capable than men to
(82.90)
34
(11.40) (1-40)
make decisions in the family
3. Men should take more responsibility for
(48.60)
(25.70) (2.90)
54
11
contraceptive use
(77.10)
(15.70) (2.90)
18
2
2
7
4. Women have more difficulties than men
45
11
in protecting themselves from STDs
(64.30)
(15.70) (10.00)
2
5. Women should be examined by the
21
16
female doctors only.
(30.00)
(22.90) (2.90)
1
(1.40)
(2.90)
8
2
6
(11.40) (8.60)
(2.90)
1
2
(1-40)
(2.90)
2
3
2
(4.30)
(2.90)
22
8
1
(31.40) (11.40)
(1-40)
1
1
(1-40)
6. Husband has right to sex with his wife
4
6
5
53
without her wish
(5.70)
(8.60)
(7.10)
(75.70) (1.40)
50
12
4
2
1
(71.40)
(17.10) (5.70)
(2.90)
(1.40)
(2.90)
7. Women suffer from health problems
because they are ignorant of their own
health needs
1
(1.40)
Disag = Disagree
Table 17: Training needs expressed by health care providers included in the facility study
Training received
Doctors (n=15)
• Cleanliness (1)
• AIDS (5)
• ORS (1)
• CSSM (5)
• De-addiction (1)
• PID/WCHP (5)
• CopperT insertion (1)
• TB(3) .
• Induction training (2)* Breast feeding (1)
• Investigations (2)
• Immunisation (1)
• Cancer (1)________ • No training received (2)
Training required__________________ ______
Need for more training expressed by 10 doctors
• Gynaecology (5)
• AIDS(1)
• Investigations (1)
• Paediatrics (2)
• Administrative (1)
• STDs (2)
• Latest developments (1)
• Computer (2)
Public health nurses (n-2)
• CSSM (2)
• PID/WCHP (2)
• Induction training (2) • TB (1)______________
Auxiliary Nurse midwife (n=10)
• CSSM (6)
• Immunisation (2)
• WCHP (4)
• Breast feeding (1)
• Induction training (3)* Leprosy (1)'
• TB (2)
• No training received (2)
• Cancer (2)
Need for more training expressed by 1 PHN
• Administrative (1)
•
Multipurpose workers (n=5)
• Induction training (5)* Family Planning (2)
• CSSM (4)
• PID(1)
• TB (3)
• Eye disease (1)
• AIDS (2)
• Breast feeding (1)
• Leprosy (2)
_________________
Community Health Volunteer (n=12)
• TB(9)
• Leprosy (1)
• PID/WCHP (9)
• AIDS (2)
• Cancer (2)
• Immunisation (2)
• Eye disease (2)
Need for more training expressed by 7 ANMs
• Women’s disease (3) • CSSM (1)
• Gynaecology (2)
• Paediatrics (1)
• Family Planning (2)
• PID (1)
• Communication skills (2) • TB (1)Report writing (1)
• STD (1)
• Latest developments (1)
• AIDS (1)________________________________
Need for more training expressed by 3 MPWs
• Gynaecology (3)
• AIDS (2)
• Paediatric (1)
• TB(1)
Need for more training expressed by 10 CHVs
• Women’s disease (5) • STD (1)
• Latest developments (4)« Investigations (1)
• Communication skills (1)
• Gynaecology (1)
•TB(1)
• Family Planning (1)
• AIDS(1)
198
| Women Centred Health Project I Report of the End Evaluation
Training received_____
Nurse (n=5)
——
Training required_______________________
Need for more training expressed by 5 nurses
• Administrative (2)
• Latest developments (1)
• AIDS (1)
• Paediatrics (1)
• Computer (1)
• Store keeping (1) * Gynaecology (1)________
Need for more training expressed by 4 pharmacists
• Latest developments (2)
• Administration (2)
—.
• PID/WCHP (3)
•Immunisation (1)
• CSSM (2)
, Paediarics (1)
• Induction training (2) e Communication skills (1)
• Breast feeding (1)
Pharmacist (n=4)
• PID (1)
• Store maintenance (1)
• Pulse Polio (1)
• Not received (1)
• Inventory control (1)
Treatment Organiser (n=1)
«TB(1)_________________
Laboratory Technician (n=2)
Not stated
• Not stated
Need for more training expressed by 2 laboratory
technicians_______________________________
• Investigation (2)
« AIDS(1)________________________________
Need for more training expressed by 2 clerks
• Latest developments (1)
• Women's diseases (1)
Need for more training expressed by 2 attendants
• Latest developments (1)
• Women’s disease (1)
• Family Planning (1)_______________________
Need for more training expressed by 1 dresser
• Dresser training (1)_______________________
Not stated
• Not stated
• Investigation (2)
Clerk (n=5)
• Not received
Attendant (n=2)
Not received
Dresser (n=4)
• Dresser training
Labour(n=3)
• Not received
Table 18: Profile of respondents
Characteristic
Sex ?
Age: Male
Female
Male
Female
15- 19
20-44
45-59
60 & +
15- 19
20-44
45-59
60 & +
Language: Marathi
Hindi+Urdu
_________ Others
DISP
H.P.
PRC
(n=203)
(n= 23)
(n=42)
23
44 (22%)
159 (78%)
32 (16%)
148 (73%)
22 (11%)
22 (11%)
148 (73%)
6. (12%)
8 (4 %)
98 (48%)
91 (45%)
14 (7%)
8.7
87.0
4.3
0.0
34.8
43.5
21.7
UHC
42
P.Hosp
(n=71)
22 (31%)
40 (69%)
28
9.5
90.5
0.0
0.0
50.0
33.3
16.7
59.0
27.3
13.6
4.1
81.6
10.2
4.1
56.4
28.2
15.4
10.7
89.1
0.0
0.0
28.5
39.3
32.2
(n=28)
TOTAL
(n=367)
66 (18%)
301 (82%)
10.6
68.2
16.7
4.5
9.3
78.7
9.0
3.0
47.7
39.8
12.5
Education:
Non-literate
M
F_
Literate upto 7std. M
F
8th-12th std.
M
F
18.7
34.0
36.4
39.0
43.1
23.9
30.5
26.2
47.9
35.7
17.3
33.3
199
1
9.12
0.44
0.95
3.05
0.02
4.5
42.9
21.5
28.5
15.23
1.2
37.9
39.9
45.2
25.2
| Women Centred Health Project I Report of the End Evaluation
M
0.0
F
2.5
4.3
2.4
2.1
Married
56.8
0.0
0.0
77.3
0.0
Unmarried
36.3
0.0
0.0
22.7
0.0
31.8
4.6
Above 12th
2.3
Marital status :
Male:
Female :
63.6
Others
16.9
0.0
0.0
0.0
0.0
Married
73.6
95.7
97.6
85.7
92.9
82.4
10.0
Unmarried
14.5
4.3
2.4
6.1
7.1
Others
11.9
0.0
0.0
8.2
0.0
7.6
22.7
0.0
0.0
13.6
0.0
19.7
18.2
0.0
18.2
Occupation :_______
Male :
Female:
Unskilled
Skilled
18.2
0.0
0.0
Service
27.3
0.0
0.0
18.2
0.0
24.2
50.0
0.0
37.9
64.5
Others
31.85
0.05
0.0
HH work
2.8
6.6
85.7
73.5
89.3
Unskilled
13.8
21.7
4.8
10.2
3.6
2.4
5.0
Skilled
11.6
6.2
4.0
4.1
5.3
Service
8.8
Others
19.6
21.7
7.1
6.0
7.1
16.8
26.1
11.9
9.94
21.4
15.8
53.5
53.7
14.6
Monthly income (Rs):
< 1000
56.6
60.8
47.6
6.54
26.6
13.1
40.5
3.6
25.1
30.5
(2616)
(2072)
(3052)
(3268)
(2180)
(2721)
1 -2
6.4
8.6
4.8
2.83
10.7
6.0
3-4
21.7
34.8
35.7
1.06
42.9
27.6
46.4
66.4
3000
1000
3000 & +
_______ (Average in Rupee)
Family Size:____________
71.9
56.6
59.5
6.2
1
65.0
65.2
54.8
45.1
67.9
60.2
2
20.7
17.4
23.8
43.7
25.0
25.6
14.2
11.1
5& +
Earning member in family
14.3
17.4
21.4
11.2
7.1
<24
4.9
8.6
40.5
11.3
14.3
24 - 59
15.3
13.1
19.0
15.5
14.3
15.5
73.3
___________ 3& +
Duration of stay (Month)
79.8
78.3
40.5
73.2
71.4
Upto 10
60.1
52.2
31.0
29.6
50.0
49.6
10 - 20
28.1
34.8
45.2
43.7
35.7
34.1
12.3
60 & +
Distance
(in
minute):
21 -40
9.4
13.0
23.8
15.5
7.1
41 - 60
0.5
0.0
0.0
4.2
7.1
1.6
1.9
0.0
0.0
7.0
0.0
2.5
Male
31.8
0.0
0.0
40.9
0.0
34.9
Female
32.1
39.1
47.6
61.2
60.7
42.2
68.2
0.0
0.05
59.1
38.8
0.03
65.1
57.8
60 +_______
Visited alone:
With escorts :
Male
Female
67.9
2.4
60.9
I
200
9.3
| Women Centred Health Project I Report of the End Evaluation
Table 19: Awareness about services available at various health care facilities
TOTAL
% of respondents
Service available
UHC
PH
PPC
HP
DISP .
n= 367
n= 28
n= 71
n= 42
n= 23
n= 203
65.1
75.0
85.9
83.3
39.1
55.7
Minor ailment
59.0
71.4
77.5
83.3
26.1
13.3
Blood Test
10.6
14.3
22.5
33.3
17.4
0.5
Urine Test
2.2
0.0
11.3
0.0
0.0
0.0
Sonography
37.9
75.0
77.5
92.8
34.8
7.9
Others
20.4
46.4
54.9
47.6
4.3
1.0
ANO
31.1
67.9
64.8
97.6
21.7
1.5
Abortion
28.6
57.1
71.4
71.8
21.7
1.5
Delivery
39.0
78.6
52.1
52.4
39.1
26.1
PNC
73.8
64.3
76.1
64.3
73.9
76.4
OB/Gyn.
72.2
67.9
71.8
57.1
69.6
76.4
Child.Immunization
73.0
67.9
85.9
16.7
56.5
82.8
Paediatric
38.4
60.7
52.1
66.7
52.2
23.2
Dressing
30.5
57.1
22.5
28.6
17.4
31.5
F.P. Methods
8.4
3.6
0.0
23.8
21.7
7.4
TB Treatment
2.5
0.0
5.6
0.0
4.3
2.0
Referral
Table 20: Reason for the present visit to health care facility
Purpose of visit
DISP
n= 203
9.5
Gastro -intestinal tract
1.4
Cardio Vascular System
19.2
Respiratory System
2.4
Gynaec. & Obst.
3.4
Ophthalmic Problems
30.1
Muscular - skeletal
8.4
Fever/Malaria
6.4
Minor Injuries
4.4
Skin problem
2.0
Paediatric services
10.8
Others
2.0
Not stated
100.0
TOTAL
HP
n= 23
8.6
% of users
PPC
n= 42
8.7
47.9
92.8
13.1
4.3
13.1
7.2
4.3
100.0
100.0
TOTAL
PH
n= 71
7.0
4.2
7.0
46.5
2.8
11.4
2.8
1.4
4.2
I. 4
II. 3
UHC
n= 28
7.1
100.0
100.0
74.9
17.9
n= 367
7.8
1.6
12.5
29.5
2.5
19.5
5.4
3.8
3.3
2.2
10.5
1.4
100.0
Table 21: Time spent at the facility for seeking services
Time
V
Upto 5
6-15
16-30
31-60
60+
Total
(in minute)
_ % of Respondents
PPC
HP
DISP
n= 42
n= 23
n= 203
0.0
17.4
1.5
2.4
34.8
19.7
2.4
30.4
23.1
11.9
13.1
19.7
83.3
4.3
36.0
100.0
100.0
100.0
201
1
TOTAL
PH
n= 71
0.0
1.4
1.4
7.0
90.2
100.0
UHC
n= 28
0.0
3.6
14.3
39.3
42.8
100.0
n= 367
1.9
13.4
15.3
17.4
52.0
100.0
| Women Centred Health Project I Report of the End Evaluation
Table 22A: Cost of travel
Dispensary
Mode of travel
Walking
Rickshaw/Taxi
Bus
Train
Cost of travel
Less than Rs.5
Rs. 5 - 9
Rs. 10-19
Rs. 20 - 39
More than Rs. 39
n=203
%
97
1
2
Health Post Post
Partum
Centre
n=23
n=42
%
96
4
%
71
24
5
3
5
3
1
1
n=71
%
49
31
14
6
4
n=36
2
11
14
5
2
n=12
n=1
n=6
1
1
4
Urban
Health
centre
n=28
%
96
Peripheral
Hospital
n=1
1
Total
n=367
%
85
10
5
1
n=54
3
15
25
8
3
Table 22B: Cost of travel by condition for which health care is sought
Purpose of visit
Ante natal care
Obstetric
Minor ailments*
Major ailments**
FP operation
Cu-T insertion
Paediatrics
Other___________
Total
Note: Valid cases only
Less than Rs. 10
4
5
4
1
Cost incurred on travel_________
More than Rs. 19
Rs. 10- 19
3
12
3
3
5
7
3
1
1
2
17
2
31
8
Table 23: Client - provider communication
_____
Respondents
PerH
PPC
HP
DISP
n=71
n=42
n=23
n=203
Enquired only about symptoms
Enquired & examined minimally
Enquired, examined minimally
gave prescription and asked to
come for a follow-up.
Enquired, examined in detail, told
the diagnosis, gave prescription
and asked to come for a follow-up
Total
Total
19
11
9
8
3
1
1
4
54
UHC
n=28
Total
n=367
%
30.0
31.1
%
26.1
30.4
%
23.8
35.7
%
22.5
19.7
%
25.0
32.1
%
27.2
29.4
17.2
30.4
28.6
35.2
28.6
23.6
21.7
55.2
13.1
6.3
11.9
11.5
22.5
19.4
14.3
7.6
19.8
100.0
202
| Women Centred Health Project I Report of the End Evaluation
Table 24: User’s satisfaction with the staff behaviour and advice given by the doctor
Facility
Particular
HP
(n=23)
a. Behaviour
- Doctor
Other staff:
1. Clerk
2. Nurse
3. Attendant
b. Advice given
a. Behaviour
- Doctor
Other staff:
1. Clerk
2. Pharmacist
3. Attendant
4. Lab.Technician
b. Advice given
a. Behaviour
- Doctor
Other staff;
1. Clerk
2. Nurse
3. Pharmacist
4. Attendant
5. Lab.Technician
b. Advice given
a. Behaviour
- Doctor
Other staff:
1. Clerk
2. Nurse
3. Pharmacist
4. Attendant
5. Lab.Technician
b. Advice given
a. Behaviour
- Doctor
%
DISP
(n=203)
PPC
(n=42)
P.HOS
(n=71)
UHC
(n=28)
Other staff:
1. Clerk
2. Nurse
3. Pharmacist
4. Attendant
5. Lab.Technician
b. Advice given
Not satisfied
Could be
better %
Satisfied
%
82.6
56.5
34.8
43.5
21.7
Not stated
%
4.3
13.0
4.3
43.5
65.2
56.5
73.9
75.4
2.0
22.2
0.5
90.1
90.6
20.2
5.9
19.2
2.5
5.9
6.4
0.5
6.4
1.5
3.0
79.3
93.6
72.4
85.7
9.5
4.8
92.8
42.9
45.2
20.2
5.9
19.2
2.3
7.1
0.5
2.0
6.4
4.8
50.0
54.8
79.3
93.6
72.4
81.7
7.0
11.3
0.0
78.9
35.2
53.5
28.2
19.7
42.3
7.0
4.2
2.8
2.8
14.1
9.9
14.1
26.8
2.8
4.2
0.0
0.0
50.7
42.3
77.5
52.1
0.5
2.0
0.5
1.4
10.7
89.3
3.6
14.3
85.7
39.3
57.1
35.7
25.0
39.3
17.9
I
203
I
10.7
46.4
42.9
46.4
75.0
60.7
i Women Centred Health Project I Report of the End Evaluation
Reasons for dissatisfaction
Table 25: Reasons for dissatisfaction
% of users
HP
PH
DISP
PPC
n 7
n 3
n =8
n =6
1. No diagnosis for child.
2. Disrespect
3. Closed in evening
4. Treatment not good
6. Doctor not good
7. Away from house
9. Not Stated
10. Others
UHC
n 1
2
1
1
3
1
1
2
TOTAL
4
3
1
1
2
1
q
Table 26 Annexure 1: Socio-economic profile of respondents
(Exit interviews at gynaecology outpatient clinics at health posts
Health Posts
Pila Bunglow
Shastri Nagar S V Nagar Welkar Wadi
6
8
15
16
Sample size
Age in years
Less than 18
18 - 25
26 - 30
31 - 35
41 - 45
More than 50
Marital Status
Married
Unmarried
Widow
Education__________ _
Can not read and write
No formal education,
can read and write
Std. 1-4
Std.5-7
Std. 8- 10
Std. 11-12
Std. 13-14
Occupation
Home makers
Service
Information not available_____
Monthly household income
Less than Rs. 2000
Rs. 2001 - 4000
Rs. 4001 - 6000
1
6
4
1
2
1
2
1
3
6
3
4
1
2
12
3
13
2
1
4
5
4
2
2
6
2
3
6
1
1
13
1
4
1
1
7
15
1
2
6
3
4
1
4
1
204
1
3
17
10
7
5
3
37
7
1
1
10
1
2
2
1
2
11
16
2
2
3
3
38
4
3
2
17
3
15
5
1
8
5
Total
45
6
1
1
5
4
n =25
1
2
1
4
1
4
5
7
i Women Centred Health Project I Report of the End Evaluation
Table 27: Reason for seeking treatment at the gynaecology out-patient clinic at health post
Health Posts
Reason for seeking treatment
Shastri Nagai| S V Nagar Welkar Wadi Pila Bunglow Total
n=45
n=16
n=6
n=15
n=8
9
4
3
White discharge
3
1
8
4
Itching, boils on external genitlia'
3
11
4
2
3
2
Pain during menstruation
2
Irregular periods
1
1
1
Menorrhagia
1
2
1
1
Infertility
2
1
For Cu-T insertion
1
2
1
1
To check Cu-T
1
For Cu-T removal
1
1
1
Pain during intercourse
1
1
Prolapse uterus
6
6
Aches and pains (back, arms, legs)
2
7
Other
3
1
1
To
Table 28: Profile of the VN Desai and MW Desai Hospitals
V. N. Desai Hospital
M.W.Desai Hospital
Santacruz (East), H/E ward
Malad (E), P/N ward
Location__________________
162
Bedstrength
251______________________
Services available at hospital
• Medicine
• Medicine
• Surgery
• Surgery
• Obstetrics and Gynaecology
• Obstetrics and Gynaecology
• Paediatric Medicine
• Paediatric Medicine
• Orthopaedic Surgery
• Orthopaedic Surgery
• ENT
• ENT
• Ophthalmology
• Ophthalmology
• Psychiatry (Department from
• Casualty
Cooper Hospital housed in
the same building)
• Casualty________________
Number of beds for Obstetrics and Gynaecology_______________
|
70
~
40
Number of Gynaecology OPDs per week
|
6 3
Average number of patients per gynaecology OPD_____________
|
60
60
Staff at gynaecology OPP
Resident Medical Officers (2)
Honorary Gynaecologist (1)
Staff nurse (1)
OPD attendant (1)
Sweeper (1)
205
1
Resident Medical Officers (2)
Honorary Gynaecologist (1)
Staff nurse (1)
OPD attendant (1)
Sweeper (1)
| Women Centred Health Project I Report of the End Evaluation
Table 29: Socio-economic profile of respondents Baseline study for documentation of client provider communication
Age in years_________________________________
11 - 14
15-20
21 -25
26-30
31 -40
41-50
>50_________________________________________
Marital Status________________________________
Married
Unmarried
Widowed
__________________
Education___________________________________
Can not read and write
No formal education but can read
Upto Std. 4
Std. 5-7
Std. 8-10
Std. 11 -12
Diploma after 10th/12th
Graduation
Post graduation___________________________ ___
Occupation of earners (husband and others)_____
Self employed
Work in a factory
Work at small inductrial unit
Semiskilled Unorganised Sector —Self employed
Employee of state / central government / undertaking
VND%
n=290
<1
13
36
27
15
5
1
n=293
97
2
J___
n=241
23
1
17
30
30
4
1
<1
<1___
n=140
■46
38
35
32
17
17
15
14
Semiskilled Unorganised Sector - Employed
Husband not employed
Sales person in a shop
Piece meal job (daily wages)
Farmer - own land
Can not say
BMC employee
Vendor (fruits, fish etc.)
Clerical job
Domestic help
Retired (pension)
Unskilled Unorganised Sector - Self Employed
10
8
8
6
5
5
3
1
Note: Percentages calculated on valid responses only.
%= percentage
MWD %
n=318
10
38
27
18
7
3
n=322
99
<1
2____
n=302
24
3
7
26
31
3
1
<1
<1
n=292
33
37
11
15
7
12
5
8
8
7
1
1
4
1
2
1
206
I Women Centred Health Project I Report of the End Evaluation
Table 30: Profile of women who were accompanied by husbands
MWD_________
VND
219(72%) n=303
147 (50%) n=293
Accompanied by relative /friend__________________
113(52%) n=TT9~
62(42%) n=147
Accompanied by husband_______________________
Median age for respondent accompanied by husband
n=112
n=51
Education_____________________________________
25%
37%
Can not read and write
5%
No formal education but can read and write
6%
6%
Std. 1 - 4
25%
23%
Std. 5 - 7
31%
24%
Std. 8- 10
2% 6%
Std, 11-12
Diploma after 10th / 12th
2% 2%
2% 1%
Graduation
2% 1%
Post-graduation
Table 31: Agewise distribution of three most common conditions for which treatment was
sought (Baseline)
Age group
(years)
16-20
21 -25
26-30
31 - 35
34-40
41 -45
VND
MWD
n=40______________________________
• Confirmation of pregnancy (38%)
• Menstrual disorders (25%)
• Problems during pregnancy (25%)
• Pain abdomen and lower backache (20%)
n=106_____________________________
• Problems during pregnancy (18%)
• Confirmation of pregnancy (17%)
• Pain in abdomen, lower backache (12)
• For D&C (12%) __________________
n=80______________________________
• Problems during pregnancy (20%)
• Menstrual disorders (19%)
• For D&C (18%)
_______________
n=33______________________________
• Pain in abdomen, lower backache (27%)
• Menstrual disorders (18%)
of
• Missed
periods/confirmation
pregnancy (15%)
• RTIs (15%)
• Problems during pregnancy (15%)
n=12__________________________
• Pain in abdomen, lower backache (5 )
• Menstrual disorders (4 )
• RTIs (2)
• Prolapse ( 2)________
n=9______________________________
• Menstrual disorder s ( 5)
• Prolapse (3)
n=31__________________________
• Mass/swelling/pain uterus (29%)
• Confirmation of pregnancy (26%)
• Problems during pregnancy (23%)
46-50
n=6______________________________
• Pain in abdomen, lower backache (2)
• For hysterectomy (1)
51 -55
n^l______________
• Prolapse uterus (!)
61 -70
n=122_________________________
• For D&C (25%)
• ForTL(21%)
• Problems during pregnancy (20%)
n=89__________________________________
• ForTL(36%)
• For D&C (34%)
• For Copper T (18%)____________________
n=45______________________________ ____
• RTIs (22%)
• Pain in abdomen, lower backache (12%)
• ForTL(18%)
• Missed periods/confirmation of pregnancy (13%)
• Menstrual disorders (13%)
• For D&C (13%)
__________________
n=13________________________
• Menstrual disorders (7)
• Mass / swelling / pain uterus ( 4)
• For hysterectomy (3 )___________________
n=35______________________________ ___
• Menstrual disorders (4)
• Pain in abdomen, lower backache (1)
• For hysterectomy (1)
• Mass/swelling/pain uterus (1)___________
n=4___________________________________
• Menstrual disorders (2)
• Other complaints (2)
• RTI (1)
• Mass / swelling / pain uterus (1)_________
n=4______________
• Prolapse uterus (3)
• RTI (1)
• ‘Pain in abdomen, lower backache (1)
• Complaints after surgery (1)_____________
n=5___________________________________
• RTI (3)
• Prolapse uterus (2)
• Pain in abdomen, lower backache (2)
n=1________________
• Other complaints (1)
207
1
| Women Centred Health Project I Report of the End Evaluation
Table 32: Why did you feel that the doctor listened to you carefully?—Indicators of perceived
attentiveness of doctors
MWDN=318(%)
VNDN=291(%)
Asked questions in response to what client said
Did not speak to anyone else while talking to client
Recorded all client said on paper
Looked at client while she talked
Feel like talking to doctor
Explaining properly
Was nodding in response to what client said
Saw reports before talking
Asked questions____________________________
Note: Valid responses only
15
5
43
46
16
4
44
28
<1
1
2
1
30
<1
29
Table 33: Communication with doctor________
MWD
322(n=322)
12(n=14)
322(n=322)
18(n=322)
318(n=322)
7(2%)(n=322)
1(n=322)
1(n=322)
295(n=296)
Indicator__________________________________ __________
1. Client could answer all questions asked by the doctor
2. Client could answer questions regarding sexual relations
3. Client could tell the doctor everything she wanted to
4. Doctor asked if client had any other complaints
5. Client could talk freely with the doctor
6. Client felt shy while talking to doctor
7. Client could ask private questions
8. Doctor answered private questions asked by the client
9. Client understood the information given by the doctor
10. At the end of the consultation, doctor asked if the client had
VND
293(n=293)
38(n=45)
292(n=292)
183 (n=293)
284(n=293)
11(4%)(n=293)
—(n=3)
any doubts
11. Client asked questions to clarify her doubts
12. Doctor answered the client’s questions / clarified doubts
13. Doctor told the client about findings of pv examination
14. Doctor informed the client about diagnosis/ why she had
—(n=304)
1(n=294)
38(n=304)
38(n=)293
36(n=36)
38(n=38)
96 - 38%(n=254) 68 - 33%(n=203)
290(n=293)
68 - 24%(n=289)
111 -37%(n=304)
Table 34: Reassurance during per vaginum examination
VND
~
Indicator_______________________ .__________________ _
4(n=256)
1. Doctor made efforts to lessen client’s fear during pv
1n=256
2. Doctor made efforts to reduce client’s shyness during pv
83
(32%)(n=257)
3. Doctor talked to client during pv
MWD_________
1(n=203)
— (n=202)
22(11%)(n=203)
the symptoms
Table 35: Felt scared during PV and previous knowledge about PV
MWD
------ -------------------------------------------------- VND
201
2T4
Knew what to expect in a pv examination
38(19%)
41(19%)
Was scared during pv examination
15
45
Did not know what to expect during a pv examination
7
27
Was scared during pv examination
208
1
Total
415
79(19%)
60
34(57%)
_____
| Women Centred Health Projectl Report of the End Evaluation
Table 36: Profile of respondents who reported missing turn while waiting for consultation
Missed turn while waiting
Age
19-20
21 -25
26-30
31 -35
36-40______________
Education___________
Can not read and write
Std. 5 -7
Std.8-10
Not recorded__________
Occupation__________
Home maker
Earner
Not recorded__________
New I Old case paper
New
Old
in corridor
for history taking
VND(n=9)|MWD(n=2) VND(n=5) MWD(n=1)
for pv examination
VND(n=5)
MWD(n=1)
3
2
4
1
1
5
2
1
1
2
2
1
1
2
1
2
2
1
5
1
2
1
2
2
1
1
5
2
2
1
1
5
4
1
1
3
1
1
4
4
1
1
1
1
1
5
1
Table 38: Satisfaction with services received
Indicator________________________________________
VND
Satisfied with services_____________________________ 278(95%)(n=295)
Gave suggestions for improvements in quality of services 82(28%)(n=295)
Suggestions for improvement regarding_____________
1. Behaviour of Opd attendant
2. Crowds in the OPD
3. Behaviour of nurse
4. Behaviour of doctors
5. Availability of drugs at the hospital
6. Good care of patients
7. Privacy in the OPD
8. Seating arrangement for patients
9. Availability of investigations at the hospital
10. Need for more doctors in the OPD
11. Availability of information centre
12. Behaviour of other staff
13. Timings for investigations
14. Seating arrangement for accompanying persons
15. Clean toilet
16. Availability of drinking water
17. Keeping appointments for investigations
18. Availability of lady doctor for examination
19. Letting in patients in a queue
20. Careful handling of case papers
21. Cleanliness at the hospital
22. Any other
23. Reduction in case paper fees
24. (code 19)
25. Time consuming (long waiting hours)
26. Allowing accompanying person inside the OPD
209
n=82
28
21
14
13
10
9
4
3
3
3
2
1
1
1
1
1
1
1
1
1
1
1
1
%
34
26
12
16
12
11
5
4
4
4
2
1
1
1
1
1
1
1
1
1
1
1
MWD
292(95%)(n=305)
55(18%)(n=305)
n=55
9
3
8
13
11
4
%
16
5
15
24
20
7
1
9
2
2
16
4
2
4
3
3
1
2
5
5
2
4
3
1
3
1
5
2
5
2
| Women Centred Health Project I Report of the End Evaluation
Annexure 2
Table 1: Studies for end evaluation
Study___________ Objective
Methodology
Client satisfaction • To
Tools
study - gynaecology
experiences regarding gyna
Exit interviews at each of the Semi structured
gynaecology OPDs at Interview schedule
OPD at health posts
ecology OPDs at health posts (in
health posts - in project as
reference to Patients’ Rights)
well as other wards.
document
the
clients’
• To explore the possibility of further
improvement in quality y of care to
meet clients’ expectations______
Client satisfaction • To assess effectiveness of the
study —
clients
counselling services offered at the
VND counselling centre
availing of services
at counselling booth • To identify unmet needs of clients
approaching the counselling
atVND
centre atVND
• To document the expectations of
• Exit interviews
• Interview guide
line
• Review of records of • Observation che
counselling
cklist
• Framework for
analysis of records
of counselling
• Observation of counsellor
clients from the counselling centre
• To explore the possibility of
meeting the clients’ unmet needs
• within available resources_____
Client satisfaction • To assess the effectiveness of the
IEC material developed by the
study — women
participating in IEC
Group
• Focus
• FGD guideline
Discussions with CHVs
who had been trained in
Project
RTIs using MB.
activities at VND
gynaecology OPD
Documentation of • To document client-provider
client - provider
Exit interviews of women
Same tool as for
baseline.
communication
communication
Awareness about • To assess the knowledge, skills
sexual health and
prevention
of
sexually transmitted
and attitudes of participants of
FGDs after pre and post Pre and post test
FGD guideline
evaluation
Stepping Stones workshops in
the community
infections, gender
and communication
Interviews with all staff at the Interview guide
pers To document experiences of health
pective regarding care providers with gyna-ecology
health
Gynaecology OPDs clinics at health posts
gynaecology OPDs
Providers’
posts
with
at health posts
clinical services provided by the
Review of reports of tech Technical supervi
nical supervision (routine sory checklist
gynaecology clinics at health posts
+conducted
To document health care providers’
evaluation)_____________
Interviews with health care
perspective women’s towards
providers
To assess technical quality of
reproductive
health
(gender
210
involved
end
in
provision of gynaecological
services
sensitisation)
for
Women Centred Health Project I Report of the End Evaluation
Study___________
Providers’ pers
pective regarding
IEC
Quality
of
counselling at the
VND counselling
centre
€
of
Records
utilisation
of
at
services
gynaecology
outpatient clinics at
health posts and
dispensaries
of
Review
resources
at
gynaecology clinics
Objective_____________________
To assess efficiency of the staff in
using participatory methods for
health education
Methodology___________
Observation of health Guideline for focus
workers conducting health group discussion
education
sessions Tools
Interviews with health Checklist
workers conducting health
education sessions using
material developed by Guideline
WCHP________________
To assess the quality of counselling Review of protocols
Observation of the process
at the booth
of counselling by external
counsellor Review and
Counselling checklist
analysis of case records
To assess appropriateness of the
intervention
Review of data
Framework
analysis
To assess effect of inputs by WCHP
Observation
Proforma
I
211
for
i Women i
ill re J I IcalLh Project I Report of the Encl Evaluation
Annexure 3
Table 1: Chronological listing of key activities related to men’s
involvement in reproductive health
Objectives___________ Participants
Main Learnings
1. Brainstorming meeting June 3,1997
Capacity building of WCHP team_____
Important reasons for involving men were noted as :
• To discuss and WCHP team
• Men are decision makers in the family
formulate rationale
• AIDS epidemic has shown that men have sex outside
for men’s involve
marriage leading to transmission of infections to wives
ment in women’s
• Men’s sexual health problems should be addressed
health
and
as they affect women’s health
for
strategies
involving men
WCHP team
2. Feedback meeting with expert in qualitative research methods July 25, 1998
Capacity building of WCHP team__________________________________ _____
• Interviews to focus on health workers’ interaction with
* To obtain feedback WCHP team Dr. Pelto
men and on topics directly related to men’s
on interviews with
involvement.
health care provi
• In interviews with community men and women, the
ders and community
focus should be on husband’s role.
men WCHP team
• Dr. Pelto suggested free listing of responses to find
Dr. Pelto
out what men generally do with respect to women’s
health and obstacles in way of husband accompanying
woman to hospital
3. Workshop with MPWs, August 28 1998
Research
• All participants agreed that involving men in women’s
MPWs, WCHP
• To find out the 21
reproductive health related activities is necessary
opinion representatives
MPWs'
• Strategies suggested at the workshop focused around
about
men’s
contacting men at timings convenient to them and
involvement
in
creating awareness among men about women's
women’s health
illnesses.
• To identify MPWs
• In secret voting, six MPWs expressed willingness to
interested in partici
work with the Project
pating
in
the
exercise to study the
existing situation
with regards men’s
involvement
in
women’s health
4. In-depth interviews with MPWs — 8 interviews March to September 1998
Research__________
• Work hours of men and MPWs coincide therefore MPWs
• To
find
out WCHP team
do not meet men
opportunities where
•
MPWs do not feel comfortable to discuss reproductive
the workers meet
health
issues
men during the
•
MPWs
believed
that men could be motivated to accept
course of their work
contraception through women
• MPWs suggested that rapport could be established
with men at party offices, community halls,
immunisation camps
• MPWs could work on holidays and at lunch hours to
contact men.
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Objectives
| Participants_______________________
Main Learnings
5. In-depth interviews with ANMs - 5 March to September 1998
Research_________
• Most of the ANMs felt the need to involve men and to give
• To understand the WCHP team
information about women’s health. One of the ANMs
nature of work
feared that such information could give men control over
• To explore ANMs’
women
views about men’s
• ANMs talk to men only if their wives ask them to
involvement
in
• Major problem with involving men is that men are not
women’s health
available at home during the duty hours of health workers
• To
find
out
•
According to ANMs, efforts for involving men in women’s
problems
with
health should start with schools and colleges.
men’s involvement
•
Meetings should be organised in the community at
• To obtain sugge
timings convenient to men
stions regarding
• Women do not want their husbands to undergo
strategies
for
vasectomy as they perceive that vasectomy might affect
involving men
masculinity.
• To understand wo
men’s attitude towards family planning__________
6. In-depth interviews with CHVs - 5 March to September 1998
Research_________
• CHVs generally do not talk to men as they are not at
• To understand WCHP team
homes at the time of their visits.
nature of work of
• Some men speak rudely with CHVs, some approach them
CHVs and to find
for their wives’ problems.
out if they commu
nicated with men
in the community_____________________ _____ ________________
7. Focus group discussions with men (4) and women (6) March to August 1999
Research_________
• To explore aware Members of IEC Core • Men would like to have information on gutkha, TB,
menstrual disorders, anemia among women,
WCHP
ness about the BMC Committee,
contraceptives and their side effects
health services — representatives
• Group meetings were preferred media for health
especially health
information by both men and women
posts and health
• Men would prefer men and women would prefer women
care providers
health educators
• To understand
• At present men feel excluded from the health care
information needs
services. They would like male health workers to visit
• To demonstrate to
them at homes and to enquire after their health
IEC Core Commit
tee members the
process of develo
ping IEC material
in a participatory
manner_____
t
___________________
8. Protocol for study on men’s involvement in women’s health June 1998, October 1999, March 2000
Research_________
Issues covered included:
• To understand WCHP representatives
• Men’s and women’s awareness about reproductive health
nature and extent
• women’s expectations from men and men’s perceptions
of
husbands’
about women’s expectations regarding 1) economic
involvement in
support, 2) physical support, 3) emotional support
health seeking
• Men’s and women’s perception of men’s role and
and
women’s
responsibilities in reproductive health
expectations from
• Communication between husband and wife regarding
their husbands in
reproductive health issues, decision making and
terms of support
negotiations
during illness
• Role of BMC health care providers regarding men’s
responsibilities in reproductive health
• Feelings about present RH event
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I Women Centred Health Project I Report of the End Evaluation
I Main Learnings
Objectives
| Participants_____________________________
9. Review of interviews of men and women from community by Dr. Bert Pelto March 2000
Research
____
• Dr. Pelto asked the team to focus on decision making
WCHP team
• To obtain feedback
as it is an unexplored area
on data gathered
• Data lacked descriptive aspect, for example terms like
in order to revise
; ‘tension’, ‘worry’ etc. used commonly by respondents
the tools/technique
were not explored
for data collection
• Methodology for collecting such data was discussed
and to seek guida
nce for using this
data for meeting the
Project objectives
10. Study on understanding barriers in men’s involvement in women’s health : 40 men and 3 health care
Research_________________
providers were interviewed November - December 20003
WCHP team, student • Men accompany their wives when they foresee need
» To find out difficul
for expenditure, when their consent is required as in
social workers placed
ties / obstacles faced
case of surgery, when woman is not familiar with the
with the project
by the men acco
setting and has traveled from far away places, or is
mpanying women
unable to communicate with the health care providers
to the out patient
due to language barrier
clinic of the hospital
• Men perceive accompanying wives to the hospital to
• To explore health
be their duty and do it as a token of care and support
care providers’
(this finding is corroborated by interviews of men and
views
about
women in the community)
involving men in
• Some of the men who accompany their wives to the
women’s health
hospital would like to be involved in the consultation
process and to find out about their wives’ conditions
from the doctors.
• It is the attendant’s experience that men entering into
the consultation room cause discomfort to other
women. Attendants think that doctors do not like men
to be present in the consultation room and hence do
not allow men to enter unless doctors ask for them
• Doctors feel that men cause embarrassment to other
women but also see potential positive aspect in
involving men in consultation process.
• According to doctors, men if involved would be able to
help women comply with the advise and assume
_________
responsibility in family planning_________________
11. FPAI workshop on Men and Sexuality November 8, 2000
Capacity Building for MPWs
• Workshop can be an effective medium / method for
• To sensitise the 13 MPWs from H/E
initiating a discussion on issues around sexuality.
participants towards ward,student social
•
It helped reduce inhibitions of the participants to some
issues related to workers placed with the
extent
and made participants aware of their attitudes
Project,WCHP
sexuality
towards
issues related to sexuality
• To enable partici Representatives
pants to discuss
issues
sexuality
with men in the
community
• To enable partici
pants to guide and
refer men to appro
priate centres for
clinical help and
information.
214
1
s Women Centred Health Project I Report of the End Evaluation
I Main Learnings
Objectives___________ | Participants_____________
12. Three workshops on sexuality and gender organised by Tathapi 2000 - 2001
Capacity building of WCHP team_________ _______________________________
7
n
wchp
representatives,
______________________ 1 MPW________ |_______________________________
13. Four workshops on sexuality conducted by IWID 2000-2001
Capacity building of WCHP team
7
WCHP irepre______________________ sentatives
14. Abhivyakti / Tathapi v workshop at Nasik
Capacity building of WCF P team_______________
•
Training Coordi
nator of WCHP
______________________ and 1 MPW___________
15. Meeting with MPWs from G/N January 25, 2001
Research__________
MPWs from G/N, • It is the MPWs’ experience that women’s response /
• To discuss experie
involvement is much more than men as far as reproductive
W
C
H
P
nces of MPWs and
health is concerned.
representatives
difficulties faced by
• Men lack knowledge about their own bodies and this
them in working
contributes to their irresponsible sexual behaviour
with men in the
• Some of the participants perceived it to be their duty to take
community
care of the family. Most of the respondents helped their
• To discuss role of
wives / mothers in household chores.
MPWs in the RCH
• Duty hours not being consistent with timings when men
• To inform them
are at home was reported to be one of the major problems
about the FPAI
in men’s involvement
workshop
16. FGDs with ANMs, MPWs and with community men and women July-August, 2001
Research__________
• To
understand
health care provi
ders’ and community
men and women’s
knowledge, attitude,
and practice rega
rding ANC
• To produce gender
sensitive
IEC
material on ANC
ANMs, MPWs • Health providers’ knowledge regarding ANC and role of
men is limited so first step is to sensitise them
from G/N, HZ
Emen
and • Gender norms prevailing in the society does not allow
men’s participation in women’s health. Gender roles are
from
women
fixed in the minds of women
posts
health
from G/N and • There is need to generate an IEC material which will bring
gender sensitivity among men and women
H/E
17. Workshop on ‘Men’s Sexuality and Constructions of male identity’ organised by Tathapi Trust August
9-12, 2001 Capacity building of WCHP team___________________________________________
W
C
H
P
• To
share
representatives
experiences and
People
from • Words like man, woman, sex, gender reflect prevalent social
insights of WCHP
nations and images that influence construction of gender*
NGOs
from
all
with other NGOs
How ‘sexuality’ is socially constructed and biological
over
India
understand
• To
aspects
of sexuality’
like
concepts
•
How
masculinity
is socially constructed
and
‘power’
•
What
is
power
and
power relations in society
‘change’
basic
• Build
common perceptive
to work with men
215
| Women Centred Health Project I Report of the End Evaluation
A
A
Objectives
|
Participants
| Main Learnings
18. Workshop on ‘Sexuality’ September 6-8, 2001
Capacity Building for MPWs___________________________ __
10 MPWs from G/N • Sexuality is governed by one’s attitude towards sex and
• To
sensitise
not only to ‘reproduction’.
ward and 1 MPW from
MPWs regarding
H/E ward WCHP • Workshop provided a forum for discussion regarding
different aspects
sexual behaviour and act.
representatives
of ‘Sexuality’
• Issues related to sexuality are important for counselling.
• To feel them ease
Use of case-studies as basis for discussion was
in talking on
appreciated by participants.
‘sexuality’ with
• Religion, caste, play important role in use of family
community men
planning methods
19. Workshop on ‘Gender and Health’ Organised by WOHTRAC, February 12-27 2002
Capacity building for WCHP team
Research Coordinator, • Social issues cannot be dealt with justice in isolation of
• Staff handling
gender perspective
Research Officer
‘Men’s
• The course gave a new vision which can be applied in
I nvolvement’
future activities, health interventions
activities should
&
K,
ir
understand
concept
of
gender sensitive
research policies
and programmes
and plan gender
sensitive_________________________________
20. Workshop on ‘Gender and Health’ March 11-15, 2002
Capacity Building for MPWs
• The pre-post exercise showed positive change in MPWs’
26 MPWs
• To gain clarity on
knowledge, attitude, beliefs regarding linkages between
3 CDOs
of
concepts
gender and reproductive health.
WCHP
and
‘Gender’,
• Importance of community involvement and partnership
Representatives
‘Reproductive
was emphasised.
health’
• To understand
the
linkages
between ‘gender
and health’ and
its differential
impact on men
and women________________ _____
...
-------------21. Follow up visit by Satish Singh (gender trainer, resource person for gender and health workshops tor
L
i
MPWs) from Sahyog May 17-20, 2002
MPWs from H/East, • One MPW shared his experience with an adolescent
• Follow
up
boy and expressed the need to start up work with
G/North, and K/East
and
‘Gender
adolescent boys
wards
Health’ workshop
•
Feeling of powerlessness, duties are dumped on them,
• Understand
difficulties in meeting men in the community, were
MPWs’ problems
expressed by MPWs
at their workplace
• Encourage and
guide them for
undertaking
activities with
men
and
adolescent boys
216
! Women Centred Health Project I Report of the End Evaluation
Objectives
| Participants
| Main Learnings
22. Meeting with Satish Singh (gender trainer, resource person for gender and health workshops for
MPWs) from Sahyog May 20, 2002 Capacity building for WCHP team____________________________
• To share expe
WCHP team and • MPWs s to do case studies of men and boys to explore
riences of Sahyog
Satish Singh
their knowledge about reproductive health problems and
on working with
beliefs about gender roles etc. These will be used for
boys
• identifying information needs that could be addressed
• To
develop
through training module.
broad outline of
• MPWs need clarity in concepts for e.g. on sexuality still
the training on
gender norms prevalent in their mind
• To
identify
• Gender, Power, Health, Masculinity, Role of Media in
important steps
Sexuality, etc. were some of the topics suggested by Satish
for develop-ing
curriculum to
work
with
adolescent boys
23. Group Discussion with adolescent boys June 6, 2002
Research_______
• To understand
10 adolescent boys • To build rapport with group atleast 2 sittings are needed
information
between age group of • Boys have lot of information to share like their aspirations,
needs,
15-19
WCHP
what is mean by love, changes in body, etc.
anxieties
of
Representative
adolescent boys
about sex etc.
• To
identify
particip-ants for
case studies
• To demonstrate
the steps for
doing
case
studies to MPWs
24. FGDs on MTP with MPWs September 5 - 9f 2002
Capacity building for MPWs_________________________
• To
prepare
MPWs from H/E, G/N • MPWs need information on technical aspects of MTPMPWs
need practice for conducting FGDs with men in the
MPWs
to
and K/E, student
community
social
workers,
facilitate FGDs
WCHP Represen
on MTP
• To refresh skills
tatives
acquired
by
MPWs
in
workshops on
facilitation skills
25. Workshop on ‘Tiulner Effectiveness’ organised by Abhivyakti, September 28 - October 4, 2002
Capacity building for Wfl§feflftte£)fficer
• Need assessment is must before planning training
• To
learn
• Training should be designed as per participants' needs
different
• Choice of method depends on content, objective of the
methodologies
session
used for training
• Evaluation and follow up training is must for a good traine
• How to plan,
• Issues related to gender, patriarchy, and gender based
organise and
discrimination are evident in day-to-day life.
conduct
workshop
• Role of trainee
in
facility
workshop,
217
1
I Women Centred Health Project I Report of the End Evaluation
Objectives
| Participants
| Main Learnings
26. ‘Gender and Health’ and Facilitation Workshop December 17-20, 2002
Capacity Building for MPWs__________
• To understand 14 MPWs5 Doctors • Importance of facilitation skills in conducting Theatre
difference (RCH key trainers)1
Forum
Repre • Street plays (non interactive) theatre can give information
between sex and CDOWCHP
but interactive theatre can provide information and create
gender
and sentatives
awareness
gender based
discrimination
e To Learn skills
and
develop
existing skills of
participants
27. Theatre Forum December 21,2002
Capacity Building for MPWs__________
• To demonstrate 30 MPWs4 CDOs5 • Group had knowledge about when MTP was advised, most
of this was from their own experiences or from experiences
the medium of Social Work Students
of those in the immediate family
WCHP
Representatives
interactive
•
None of the men whose wives had MTP had received any
theatre (‘Theatre
information
from health care providers
Forum’)_______
28. Group discussion with adolescent boys on MTP December 2002
Research_______
® To
explore Group of community • None of the members in the group could tell how MTP
was done
knowledge of m e n , W C H P
• Seriousness and potential danger to a woman’s life
Representatives
men about MTP
because of MTP was undermined,
so many women get
it done, it must be alright to do it.____________________
29. Health Education session on MTP December, 2002
Capacity building for MPWs_______________ _ _____________________________________________ _
• To
give Doctor (RCH Key trainer) • Men and adolescent boys appreciated information on MTP
information on Group of community • Some men preferred to clarify their doubts privately (away
from group)
men, WCHP RepreMTP
__________
sentatives____________
30. Publication of ‘Samvad’ December 2002
Capacity building for MPWs
• Writing skills that some MPWs have can be effectively used
• To encourage 4 MPWs
for the purpose of documentation
the MPWs to
document their
experiences
about activities
related to men’s
involvement in re
productive health
• To
share
experiences of
the MPWs and
about
WCHP
with
working
and
men
adolescent boys
on
issues
related to reproductive health._____________________
31. Demonstration of Mahiticha Bagicha, January 17, 2003
Capacity building for MPWs
• To
discuss Student social workers, • Adolescent boys lack knowledge regarding reproductive
organs and their functions
reproductive MPW,Adolescent boys
• Adolescent boys share their anxiety related to ‘sex' in peer
tract infections
groups
and sexual
I
218
| Women Centred Health Project I Report of the End Evaluation
Main Learnings____________________
Objectives ______ Participants
• They would like male health workers to talk to them
problems with
to understand their information needs and to provide
adolescent boys.
information and guidance to them
• To
practice
facilitation skills
of MPWs_______
32. FGD with adolescent boys at Squatters Colony January 18, 2003
Capacity building for MPWs_____
• To
document 11 boys from Squatters • Adolescent boys have a number of questions related
to sex and sexuality
Health
Post
information Colony
needs
of areaMPW-1 WCHP • Adolescent boys need information on HIV/AIDS,
sexually transmitted diseases (STDs) and
Representative
adolescent boys
reproductive tract infections (RTIs)
• To build rapport to
• Gender norms are fixed in boys’ mind
develop a group
for
further
interventions
• To select boys for
case study_________________________________
33. Stepping Stones Workshop January 27 - February f; 2003
Capacity Building for MPWs_______________
• To develop skills 13 MPWs,10 ANMs, 6
of MPWs as PHNs,4 CDOs1 FTMO 1
for C H V W C H P
trainers
discussion on Representatives
issues related to
gender, sexuality
and prevention of
HIV/AIDS_______ ___________________________
34. Workshop to prepare module to work with men organised by Tathapi, February 13 - 14, 2003
Capacity building for WCHP team
from
• Preparing men to Representatives
work with men Tathapi Sahyog Eklavya
across life stages SAHAJ WCHP
and roles on
issues of gender
and sexuality,
health based on
rights approach_____________
35. Counselling Workshop April 21 - 24, 2003
Capacity Building for MPWs________________
• To orient the 11 ANMs, 4 MPWs WCHP
participants to the Representatives
skills
and
technique
of
counselling.
• To prepare a module, it will be Training Of Trainers
• The module will be used to change attitude of
participants
• We want to make it from perspective of reinforcing
Equality, Diversity, Justice, Gender equality and
against violence
• This process helped even in preparing module to
work with adolescent boys. It was a learning process
• When provided with adequate inputs MPWs can play
am important role in meeting the information and
counselling needs of men.
219
| Women Centred Health Project I Report of the End Eval nation
Table 2: Investment in Human Resource for Increasing Men’s Involvement in
Reproductive Health
Note: Information on training inputs related to men’s involvement in reproductive health to various health care
providers is presented here with the hope that this would be a ready source of resource persons for the MCGM.
WCHP believes that all of those listed here would be assets to the MCGM in its efforts for shaping role of male
health workers in reproductive health and in developing strategies to reach out to men and adolescent boys.
Post
Name
H/E ward
Dr. Ranjana Mitra AMO
CDO
Varsha Joshi
MPW
Nitin Pawar
Vilas Rane
MPW
Shailendra
Deshmukh
MPW
Prasad Toraskar
MPW
Activity/Responsibilities
Member of Men’s Involvement committee____________________________
Member of Men’s Involvement committee
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD
Training on ‘Gender and Health, Facilitation’ workshop
Training on ‘Sexuality ’____________________________________________
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD
Training on ‘Gender and Health, Facilitation workshop’
Training on ‘Sexuality ’
Training on ‘Gender and Health’ workshop
Training on ‘Gender and Health Facilitation’ workshop
Training on ‘Sexuality’___________________________________________
Training on ‘Male sexuality and construction of male identity’
Training on ‘Gender’ organised by an NGO
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPD
Conducted FGD with adolescent boys followed by four case studies with
adolescent boys
Attended Stepping stones workshop
Conducted focus group discussion on MTP with MPWs from H/E ward
Pradip Roy
Pradip Salve
MPW
MPW
Nasiruddin
Sheikh
MPW
Vishnu Bhagat
Sanjay Khedkar
MPW
MPW
Active member of MIC
Contribution for ‘Samvad’
Training on ‘Sexuality ’
_____ _________________________
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD«Training
on ‘ Facilitation workshop’
Training on ‘Sexuality ’____________________________________________
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD»Training
on ‘ Stepping stone workshop’
Training on ‘Sexuality ’_______________________________
_________
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPD
Training on ‘Gender and Health’ workshop___________________________
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD
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| Women Centred Health Project I Report of the End Evaluation
Name
Post
Vinayak Borkar
MPW
Mangesh Khedekar
MPW
Shrawan Jadhav
Mahendra Kambli
MPW
MPW
G/N ward
Satish Sonegaonkar CDO
Dinesh Rokde
Sushil Patil
MPW
MPW
Rajesh Pagare
MPW
Rajan Parab
MPW
Sanjay Nimbalkar
MPW
Rajendra Bhongale
MPW
Abhayraj Yadav
MPW
Activity/Responsibilities
Training on ‘ Facilitation workshop’
Member of MIC
Training on ‘Sexuality’____________________________________
Training on ‘Gender and Health’ workshop
Training on ‘Facilitation skills’ workshop
Member of MIC
Training on ‘ Stepping stone workshop’
Contribution for ‘Samvad’
Training on ‘Sexuality’
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’_______________________________
Training on ‘Gender and Health’ workshop
Training on ‘Gender and Health’ workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPD
Training on ‘ Facilitation workshop’
Training on ‘Sexuality ‘
Training on ‘Gender’ organised by an NGO
Training on ‘Gender and Health’ workshop
Attended Stepping stones workshop and became a key trainer
Editor of ‘Samvad’
Training on ‘Facilitation skills’
Training on ‘Theatre Forum’
Training on ‘Sexuality ‘
Facilitation of ‘Mahiticha Bagicha’ with community men and adolescent boys
Member of MIC
Training on ‘Gender and Health’ workshop
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Active member of MIC
Active member of Module Preparation Committee’ (MPC)
Training on ‘Sexuality ‘
Facilitation of ‘Mahiticha Bagicha’ with community men and adolescent boys
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Sexuality ‘
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPD
Training on ‘Gender and Health' workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Training on ‘Gender and Health' workshop
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPD
Training on ‘ Facilitation workshop’
Training on ‘Sexuality’
221
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| Women Centred Health Project I Report of the End Evaluation
Name
Prasanna
Pangerkar
r» '
Post
MPW
Devendra Makwana MPW
Deepak Rathod
MPW
K/E ward_____
Ashok Ramteke
CDO
Dilip Devarkar
MPW
Siddhartha Gamre
Tushar Patkar
Shivram Mirlekar
MPW
MPW
MPW
•X
Sunil Kambli
MPW
Prakash Merchande MPW
Activity / Responsibility_________________
• Training on ‘Gender and Health’ workshop
• Training on ‘Theatre Forum’
• Training on ‘Facilitation skills’
• Training on ‘Sexuality’_________________
• Training on ‘Gender and Health’ workshop
• Training on 'Gender and Health’ workshop
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Active member of Module Preparation Committee’
Active member of MIC
Facilitation of ‘Mahiticha Bagicha’ with community men and adolescent boys
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Member of MIC
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology OPP
Training on ‘Gender and Health’ workshop
Training on ‘Gender and Health’ workshop
_____________________
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Member of MIC and MPC
Training on ‘Counselling’ workshop
Counselling male partners of female coming to gynaecology. OPD
Editor of ‘Samvad’
Training on Stepping stones
FGD on MTP with community men
FGD with adolescent boys
Training on ‘Gender and Health’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’
Member of MIC and MPC
Contribution for ‘Samvad’
Training on Stepping stones
FGD on MTP with community men
FGD with adolescent boys___________________________________
Training on ‘Gender and Health, Facilitation’ workshop
Training on ‘Theatre Forum’
Training on ‘Facilitation skills'
Active member of Module Preparation Committee’
'T
I
Santosh Kulkarni
MPW
Milind Desai
MPW
AnantJadhav
MPW
Active member of MIC/MPC
Training on ‘Stepping stone’
Training on ‘Theatre Forum’
Training on ‘Facilitation skills’_____________
Training on ‘Stepping stone’
Training on ‘Theatre Forum’
'__________________________
Training on ‘Gender and Health’ workshop
222
| Women Centred Health Project I Report of the End Evaluation
Name________ |I Post
P/N ward_____
Prakash Thorat CDO
Atul Kulkarni
H/W ward
Bhagwan
Vathore
|_ Activity/ Responsibility
MPW
CDO
• Training on ‘Gender and Health, Facilitation’ workshop
• Training on ‘Theatre Forum’
• Training on ‘Facilitation skills’
• Active member of Module Preparation Committee’
• Active member of MIC/MPC
• Training on 'Stepping stone’_____________________
• Training on ‘Stepping stones’
• Training on ‘Gender and Health’ workshop
• Training on ‘Theatre Forum’
• Training on ‘Stepping stones’
Table 3: Socio-economic profile of respondnets - Exit interviews for end evaluation
of gynaecology out-patient clinics
Sample size
Age (years)
15-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
Respondent did not know
Marital Status
Married
Unmarried
Widowed
Deserts
Educational status
Illiterate
Upto Std.4
Std. 5-7
Std. 8-10
Std. 11 -12
Std. 13-14
Diploma after 10/12
Graduation
Post Graduation
Occupation - Respondent
Housewife
Domestic help
Salse person in shop
Work at Small Industrial unit
Other (College)
Occupation - Husband
Sales Person in a shop
Daily wager
Self employeed
BMC emlpoyee
Employee of State/Central
Govt.
Work at Large /Small
Industrial unit
Other
Pont’ know_____________
Note: Valid responses only
Shastri
Nagar
12 •
Welkar
S.V.
Nagar Wadi
8
10
2
4
3
1
1
4
2
1
1
2
2
3
1
1
End Evaluation
Name of the Helath Post
Sambhaji Tadwadi
Gulbai
Nagar
10
6
4
3
1
2
1
1
1
1
1
2
3
2
1
1
7
9
1
2
2
3
1
4
8
43
1
2
2
6
1
1
1
1
3
5
4
2
2
6
1
1
1
1
1
12
8
3
8
1
4
8
2
1
1
1
2
2
2
3
1
1
5
1
2
2
1
5
2
1
1
7
15
10
9
3
4
3
1
3
1
4
3
50
1
1
1
1
12
Total
2
2
1
223
1
7
4
14
18
2
1
1
1
1
43
1
1
1
3
2
1
12
3
8
1
2
3
2
14
| Women Centred Health Project I Report of the End Evaluation
Table 4: Reason for seeking help at gynaecology clinics at health posts and
dispensaries
Shastri
Nagar
1) Missed periods / to
confirm pregnancy
2) Wish to have CuT
insertion
3) Pain in abdomen
during periods
4) White discharge
5) Itching, boils, swelling
on vagina
6) Prolapse
7) Pain abdomen, pain lower
back, pain in arms and legs
8) For CuT removal
9) To check CuT
10) Burning during urination
11) Weakness, dizziness
12) Can not conceive
13) Irregular periods
14) Excessive bleeding
15) Other
16) ForTL
17) Complaints after CuT
i n sertion______________
End Evaluation_____
Name of the Helath Post
Sambhaji Tadwadi
Gulbai
Welkar
S.V.
Nagar
Nagar Wadi
n=13
n=12
n=5
n=17
Total
n=4
1
1
1
1
1
4
3
3
3
1
1
3
1
1
1
1
1
1
1
3
4
1
4
1
1
1
1
1
3
1
1
1
1
1
1
4
1
12
1
2
1
1
9
3
1
2
2
1
5
2
2
1
2
1
1
1
1
1
2
1
1
1
1
1
Table 5: Reason for choosing gynaecology out-patient clinics at health posts and
dispensaries for treatment
Advised by CHV/other
staff from health Post
Suggested by friend
Other_____________
Shastri
Nagar
n=12
End Evaluation_____
Name of the Helath Post
Sambhaji Tadwadi
Gulbai
Welkar
S.V.
Nagar
Wadi
Nagar
n=6_____ n=10
n=4
n=10
n=8
9
7
3
1
n=50
35
2
12
8
6
2
3
2
5
Total
2
1
Table 6: Awareness of services available at the health post
Services available
at health post
Family planning
Midterm
End evaluation
Midterm
Treatment for T.B.
End evaluation
Midterm
ANC
End evaluation
Women’s Health related Midterm
End evaluation
Midterm
Immunisation
End evaluation
Midterm
Adolescent clinic
End evaluation
Midterm
Cough/cold, other
End evaluation
treatment
WW
n=10
1
1
1
3
1
7
1
4
1
6
1
ShN
n=12
9
3
SVN
n=8
3
2
GB
n=4
SN
n=6
TW
n=10
4
2
1
3
3
3
4
1
1
1
11
1
8
1
1
3
3
3
3
5
1
3
Total
n=50
13
10
1
19
2
7
2
10
3
36
4
3
-
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| Women Centred Health Project I Report of the End Evaluation
Annexure 4
Table 1: Key findings of end evaluation for exit interviews for documenting client
provider communication in a gynaecology out-patient clinic
VND
Indicator______________ _____________
Communication____________________
1. Client could answer all questions asked by the doctor
2.
Client could answer questions regarding sexual relations
3.
Client could tell the doctor everything she wanted to
4.
Doctor asked if client had any other complaints
5.
Client could talk freely with the doctor
6.
Client felt shy while talking to doctor
7.
Client could ask private questions
8.
Doctor answered private questions asked by the client
9.
Client understood the information given by the doctor
256
(n=256)
204
(n=205)
(n=14)
256
(n=256)
27
(n=256)
253
(n=256)
4
(n=256)
164
(n=167)
(n=11)
193
(n=205)
71
(n=203)
187
(n=205)
11
(n=205)
6
(n=203)
3
(n=4)
165
(n=176)
17
(n=255)
9
(n=255)
8
(n=9)
89
(n=135)
6
(n=205)
49
(n=204)
48
(n=49)
31
(n=88)
125
(n=254)
97
(n=204)
24
(n=256)
3
(n=251)
133
(n=136)
27
(n=205)
3
(n=202)
75
(n=81)
(n=3)
10. At the end of the consultation, doctor asked if the client
had any doubts
11. Client asked questions to clarify her doubts
12. Doctor answered the client’s-questions / clarified doubts
13. Doctor told the client about findings of pv examination
14. Doctor informed the client about diagnosis/ why she had
the symptoms
MWD
Privacy___________________________
15. Communication with doctor was disturbed
16. Other patients crowded around the table
•
17. Privacy for undressing
225
i Women Centred Health Project I Report of the End Evaluation
Proposed Referral System for the Municipal Corporation of
Greater Mumbai
Introduction
A referral system is essentially a mechanism for quality assurance. In a health system with multiple tiers,
it is important to ensure appropriate utilisation of available resources. If patients have a free choice of level
of health care and bypass the primary level to avail of speciality services, it results in the wastage of
resources. In such situation the skills and resources at the speciality services are spent on managing
conditions that could have been managed at the primary level of health care delivery. Among other things,
this results in prolonged waiting time, shortage of resources at the speciality care centers and thus
compromised quality of care. Such service would be expensive for clients — in terms of time and indirect
costs of health care — and to the institute providing the service i.e. MCGM — in terms of wastage of
resources.
Budgetary allocations for curative and preventive health care provided by MCGM have been decreasing
over the past decade. With rising cost of medical care, budget constraints and staff shortage, it is
important to ensure optimum utilisation of available resources. A study of utilisation of primary (health
posts and dispensaries), secondary and tertiary level health care facilities showed that health care in
health posts turned out to be more expensive than that in hospital set up due to poor utilisation of the
health posts and dispensaries. Overcrowding at the hospital out patient clinics (OPDs) affects the quality
of care and might result in client as well as provider dissatisfaction.
/\n effective referral system would ensure optimum utilisation of three tier health care delivery system of
the MCGM and therefore of the available resources.
Objectives of the referral system
•
To ensure appropriate utilisation of available resources
•
To ensure accessible, affordable health care services
•
To ensure client and provider satisfaction
Pre-requisites of an ideal referral system
ii.
Following are the prerequisites for the referral system
• Well defined levels of health care services based on availability of speciality services
•
•
Standard referral protocols
Administrative guidelines agreed upon by appropriate authorities governing various levels of health
•
care facilities
A well-defined and well-implemented feed-back system
•
Focus on client / Client-centred in nature
•
Involvement of public as well as private sector
•
Strategies to enforce compliance
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[ Women Centred Health Project I Report of the End Evaluation
Proposed referral system for MCGM
1.
Levels of referral system
The health care delivery system of MCGM has three well-defined levels with health posts and dispensaries
as primary level, secondary hospitals, maternity homes and post partum centres as secondary or first
referral level and teaching hospitals as tertiary level.
2.
How it will work
The referral system will rely on provision of quality health care at all levels, especially at primary level and
on the principle of ‘priority to referred patient’. Patients will be referred using the Referral Protocols as
guideline. All patients requiring referral will be referred using the specially designed referral slip. Those
carrying the referral slip will be assigned priority at the referral centre on par with MCGM employees.
Patients not in need of care at referral centre will be referred back at the referring unit using the same
referral slips. This will help reduce crowding at the hospital OPDs
Results of referrals will be evaluated in monthly joint meetings of referring units and referral centres.
228
■ Women Centred Health Project I Report of the End Evaluation
Table 2: Drugs that were prescribed from outside
Drug
Anti-helminthic_____
T. B-Long
T. Cal-Lact
T. Folvite
T. FS
T. FS+FA+BC
T. FS+FA+BC+Cal
T. FS+FA+MV+BC+Cal
T. Globac
T. MV\+BC+Cal
T. MV+BC
T. Raricap -Zn
T. Zevit
T. Zincobar
Inj. Jectofer_________
Antibiotics_________
Soframycin ointment
T. Cefazolin
T. Ciplox-TZ
T. Doxy
T. Flagyl
T. Klox
T. Sporidex
T. Terramycin
T.Ampicillin
Whether available
on BMC schedule
If noton schedule,
whether alternative
is available on BMC
schedule
Whether available at
OPD pharmacy of VND
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
No
No
No
Yes
Yes
Yes
No
No
No
No
No
T.Emycin
Yes
T.Norflox________
Antifungal_______
Candid VP
Kmycetin VP
Betadine VP
T.Zocon
T. Forcan
Mycogel — LA
Anti-spasmodics
T. Meftal Spas
T. Ponstan
T. Dysmen
T. Diclonac______
Anti-inflammatory
T. Combinil
T. Cpmbiflam
T. Calpol Forte
Progesteron_____
T. Primolut N
Inj. Proluton
T. Gestin
T. Gestanin______
Anti-helminthic
T. Mebex
No
Yes
No
No
Yes
No
No
No
Yes
Yes (for BMC employees
only)
Yes (for BMC employees
only)
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Anti-emetic
T. Doxinate
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
Yes (out of stock during the
study period)
Yes
No •
No
No
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| Women Centred Health Project I Report of the End Evaluation
Anti-infertility
T. FeityI
Tocolytic_______
T. Duvadilon
Neuroregulator
T. Pacitane
T. Esperzine
Urine alkaniser
Syp. Cital_______
No
No
No
No
No
No
No
Yes
Yes
Bronchodialator
T. Bricanyl
No
Yes
Yes
No
No
No
Yes
No
Note: Whether prescribed medicine (brand name / generic drug) present on the BMC schedule
Whether alternative generic drug available
Schedule I for 1999 referred for this exercise
Table 3: Prescriptions that were fully or partially (in terms of quantity) dispensed at the OPD
pharmacy
T. Doxy
OCP
Candid VP
FSFAMVBCCal
MalaD
T. Flagyl
Septran
Liq. Parafin
Sy. Cital
T. Gellusil
Conditions seen at the gynaecology OPD at VND Hospital
Contraception
Menstrual disorders
Pregnancy related
• MTP with Cu-T
• Menorrhagia
• Pregnancy confirmation
• Change of Cu-T
• Menstrual irregularity
• ?lncomplete abortion
• TL
• Missed periods / Amenorrhoea
• Complications of pregnancy
• For Cu-T insertion
• Dysmenorrhoea
Followup
Infections
• Oligomenorrhoea
• Follow up after surgery
® Leucorrhoea
Infertility
• Old patients for follow up
• Urinary tract infection
• Primary infertility
For admission
• PID
• Secondery infertility
• In labour (for admission)
Surgery
Other
• Hysterectomy
• ? Cancer cervix
• OS Tightening
• Pain abdomen
• Ovarian cyst
• Patients for other unit
Number of prescriptions studied
• Cervical biopsy, hysteroscopy,
D&C for admission
: 148
Total number of drugs prescribed in 148 prescriptions
: 236
Alternatives to prescribed drug available for 142 drugs
Available at VND 84
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I Women Centred Health Project I Report of the End Evaluation
Minutes of the second meeting of the Working Group
Date : January 24, 2001
Venue: WCHP Office
Time : 10.00 a.m. to 1.00 p.m.
Present: Dr. Khandare, Dr. Harale, Dr. Choukkar, Dr. Keskar, Dr. Kewalramani, Dr. Ubale, Swati, Anagha
Dr. Bandiwadekar had given his feedback earlier over phone.
Agenda
•
Discussion on Patients’ Rights and Responsibilities
Proceedings
The group was informed that the Legal Department of the BMC has been informed about development of
Patients’ Charter and has agreed to review the draft produced by the Support and Working Groups. The group
was of opinion that draft should be forwarded to the Legal Department only after all the points have been
thoroughly discussed. It was also suggested that the draft needs to be developed in very simple language and
translated in simple Marathi for circulation to health care providers and members of community. It was also
suggested that these points be organised under various headings.
Meeting started with discussion on Patients’ Rights. Each of the listed points was discussed in detail.
Patients’ Rights
D Right to seek advice regarding preventive and curative medicine, after care and good health (peoples’
right)
2)
Right to information about the health services and how best to make use of them Right to health services
free of corruption and political interference
First two points were accepted without discussion. It was suggested that order of these be reversed.
Second point was modified to read
Right to information about the health services and how best to make use of them Right to health services
3)
Right to health care system that is accountable to the people
This point was discussed in detail. It was suggested that a representative from the community should be
present for the meeting conducted by the zonal AHO / DEHO and the MOH. Another suggestion from earlier
Support Group meeting was that local representatives should be invited for weekly meeting of the health
post staff and feedback of this meeting be sent to the MOH. Mechanism for feedback were discussed. It
was decided that convinient, effective and feasible method for feedback needs to be developed. Putting up
a suggestion box in each facility as suggested by the Support Group was discussed. The suggestions
would be reviewed in the weekly meetings Suggestions would be pasted in a separate register. This
register will also document action taken for each of the suggestions. This register could be reviewed by
officer concerned during supervisory visit. Other measures for making health services accountable to
people would include displaying information about the services available in the facility on a board outside
each of the facility and educating people regarding their right.
The statement was accepted without any modifications.
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Women Centred Health Project I Report of the End Evaluation
4)
Right to basic health care services irrespective of ability to pay
Discussion mainly focused on terms ‘ability to pay’ and ‘basic health care’. The group felt that the term
basic health care would refer to primary health care services provided through the dispensaries and as per
rule the case paper would be charged at Rs.10.
There was discussion about giving Medical Officers authority to waive fees for those unable to pay. It was
also suggested that the number of such cases could be restricted. Some members of the group were of
the opinion that every person in the metropolis can afford Rs. 10 hence no such provision was needed.
They believed that there is a possibility that such discount could be misused by some of the medical
officers. After long discussion it was decided that community should be made responsible for supporting
treatment of any person unable to afford even the nominal charges at the municipal dispensaries.
The group suggested that ‘treatment irrespective of ability to pay’ should be applied only to expensive
treatment and treatment in emergency situations.
Another suggestion was that fees charged at each of the facilities should be deposited in the Poor Box
Fund and the same amount be reimbursed from the ward office for use at the facility. Such mechanism if
introduced would take care of those unable to pay and also serve as an incentive for the staff at that
particular facility. This issue needs to be studied in detail and presented to senior BMC officers for further
decisions.
The fourth point was modified to read as
Right to basic health care, expensive treatment and emergency services at hospitals irrespective ability to
pay
5)
Right to access to adequate and appropriate health care and treatment (define in QA policy for BMC
Public Health Department)
6)
Right to easy access to health care services that are effective and sensitive to community's needs
(define in QA Policy)
Point 5 and 6 were clubbed together to read
Right to easy access to adequate and appropriate health services that are effective and sensitive to
community’s needs
7)
Right to effective outreach services - to the most needy
Term ‘most needy’ was discussed. It was agreed by all that the. outreach services provided by tne
Brihanmumbai Municipal Corporation are for all the residents of the metropolis and hence term for the
needy seems inappropriate. Terms ‘need-based’, ‘situation specific’ and ‘as per demand’ should be
defined in the
The statement was modified to read
Right to need-based, situation specific outreach services as per the demand of the community
8)
Right to health services that are sensitive to circumstances and needs of women (and other vulnerable
categories)
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The Group felt that ‘vulnerable categories’ need to be defined and situations or circumstances to which the
health providers need to be sensitive need to be specified. It was decided after the discussion that women,
children and elderly should be considered as vulnerable groups. The Group would like to review legal
aspects of offering treatment to child not accompanied by an adult.
The statement was modified to read as
Right to health services that are sensitive to specific needs of women, children, elderly and other vulnerable
categories.
9)
Right to expect prompt treatment in an emergency
Issue of whether health care providers at primary level should attend to emergency situations was discussed
at length. It was mentioned that the health posts and dispensaries are not equipped to manage
emergencies. If a patient needs to be transferred the staff at the health post or dispensary has to spend for
the taxi or rickshaw and sometimes to avoid the expenses patient is asked to go on his/her own to the
referral centre. After discussion the Group agreed that doctors from health posts and dispensaries should
attend to the emergency and if the patient has to be transferred by taxi or rickshaw the amount should be
reimbursed by the MOH.
The statement was modified to read as
Right to expect prompt treatment within the available resources in an emergency irrespective of ability to
pay, in the working hours of the primary and secondary health care facilities and at all times in Casualty
departments of secondary and tertiary hospitals.
10) Right to a health system that anticipates major health hazards, takes appropriate actions to prevent
those and in unfortunate instances is fully equipped to act effectively to control the damage caused by
health disasters.
This point was accepted without modification.
11) Right to be referred to hospital / consultant of his /her choice wherever applicable ( as per the areas
determined in referral protocols or liaisons between teaching and secondary hospitals)
Issue of whether patients should have choice for place of referral was discussed in detail. It was decided
that the convenience from place of residence, timings etc. would be taken into consideration while developing
the referral protocols. That is patients’ view point would be taken care of by the referral protocol itself.
Hence, it was felt that the patient should not be given freedom to chose the referral centre. The Group would
also like to review the legal aspect of referral.
The statement was modified to read
Right to be referred to hospital / consultant wherever applicable as per the referral protocols
12) Right to be transferred to another health care establishment only after an explanation of the need for
transfer and after the other establishment has accepted the patient
This point was accepted without modifications.
13) Right to considerate and respectful care (explain with examples)
•
In outreach services
•
InOPD
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As in-patients
General or applicable to all : Respecting the patient as a human being, addressing respectfully, not
looking down upon them, not labeling them — these people from Hindi speaking belt will never
understand, showing trust if a patient offers a reason for non compliance — after due verification, etc.
The statement was reworded as
Right to polite behaviour and considerate care
14) Right to information on diagnosis, treatment and medicines
This was modified to read
Right to information on causes, diagnosis, treatment, medicines and preventive measures for a particular
condition
15) Right to information about expected outcomes, side effects, after effects, chances of success, cost
and availability of prescribed medication.
Accepted without modification.
16) Right to obtain all the relevant information about the professionals involved in the patient care for
example a vailability / timin g
It was decided that names, qualifications, whether present in the facility and work hours should be displayed
at the facility
17) Right to expect that all communication and records pertaining to his/her care be treated as confidential
This point was accepted without modifications.
18) Right to every consideration of his / her privacy concerning his / her medical care programme
Issue of privacy was discussed and the Group agreed that the health services must ensure privacy of the
patient; It was suggested that it must be ensured that female attendant is present while a male doctor
examines a female patient. If female attendant or any other female provider is not available patient’s
female relative should be asked to be present during examination. •
19) Right to have all identifying information, results of investigations, details of his / her condition and
treatment kept confidential and not made available to anyone else without his / her consent
In the BMC health care services all the documents are handed over to the patient and no records are kept
with the facility. It was suggested that records of cases be kept at the facility. A register or carbon paper or
computer could be used to record relevant details of the cases. Feasibility of using carbon paper needs to
be discussed with the facility doctors.
20) Right to clear, concise explanation in lay terms of proposed procedures and available alternatives .
Wherever applicable the explanation should include information on risks, side effects or after effects,
problems relating to recuperation, likelihood of success, and risk of death. Informed consent must be
obtained prior to the conduct of treatment ora procedure. In case of a minor, consent must be obtained
from the parent or guardian. If a patient is incapacitated or any delay would be dangerous, the doctor
is entitled to carry out the procedure after a second opinion is obtained.
Accepted without modifications.
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21) Right to explicit, informed consent for participation in scientific experimentation (applicable only for
hospitals and maternity homes — review and revise existing format)
Accepted without modifications
22) Information may be withheld from patients in cases where there is good reason to believe that this
might affect patients’ health adversely, however, information must be given to a responsible relative
The Group would like to seek legal opinion on this issue.
23) Right to refuse to participate in human experimentation, research project affecting his/her care or
treatment (only for tertiary hospitals)
This point was modified as
Right to refuse to participate in human experimentation, research project affecting his / her care or
treatment
24) Right to refuse treatment to the extent permitted by law and be informed of the consequences of
the decision. (Define in QA Policy for BMC Public Health Department)
Term ‘as permitted by law needs to be defined. The Group would like to have legal opinion for this point.
25) Right to get copies of the medical records
This should be clubbed together with point 19.
26) Right to seek second opinion about his / her disease, treatment etc. (?? For BMC from teaching
hospitals
This point was discussed in detail. The group was divided over whether the patient should have a choice
to seek second opinion. It was argued that if a patient under treatment with one facility wants to seek
second opinion he/she could do so ‘against medical advice’.
27) Right to benefit from or be able to chose from advances in medical knowledge related to his/her case
(within available resources e.g.
Reworded as
Right to benefit from advances in medical sciences related to his / her case
28) All drugs dispensed shall be of acceptable standards in terms of quality, efficacy, and safety.
Accepted without modification. Underlined terms will be defined in the QA Policy of the BMC.
29) All medications shall be labeled and include pharmacological name of the medicine
The Group felt that names of medicines are already mentioned on casepaper hence there is no need to
write those on packets of medicines. However, doses should be clearly mentioned on the packets. It was
suggested that this point be deleted. One of the group members was of the opinion that this is an important
point and names must be recorded on the packets of medicines.
30) Right to know what hospital rules and regulations apply to him /her as patient and the facilities obtainable
to the patient (applicable to primary facilities — in terms of user fees, referral, etc.)
Accepted without modifications.
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31) Right to get the details of the bill (receipts for amounts paid for BMC)
Accepted without modifications.
32) Right to have access to appropriate redressal procedure.
Accepted without modifications. This would entail installing complaint boxes at all facilities and developing
a mechanism for redressal of complaints.
33) Right to legal advise regards any malpractice by the hospital, hospital staff or other health professional
Modified to read as
Right to legal advice within the jurisdiction of Mumbai regards any malpractice by the hospital, hospital staff
or other health professional
34) Right to standard treatment from public as well as private health care providers
Since there are no mechanisms existing at present which control the private health care providers, the
statement was modified to read as
Right to standard treatment from public health care services / providers
35) Right to humane terminal care and to die in dignity
This issue was discussed in detail. It was agreed that though there is no law as yet regarding euthanasia
it is important to document this in the charter. A note stating this will be attached to this point. Term ’die in
dignity’ should be explained in detail. It should include respectful handling of the body after death.
(Draft of Patients’ Rights Compiled from:
Pondicherry Declaration on Health Rights and Responsibilities
Manual of Patient’s by ACASH
People’s health Charter for Gujrat
Final Draft of People’s Health Charter)
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Patients’ Responsibilities
1.
To faithfully undergo the agreed therapy
2.
To follow the doctors’ instructions diligently
3.
To take the necessary preventive measures in case of infectious diseases as per the doctor’s
instructions
First three points were accepted without any modifications.
4.
To be aware that doctors and nurses (and paramedical staff) are also human beings and amenable
to mistakes and lapses
This point was discussed at length. Group felt that this point should be kept at the end of the list. It was
also felt that this seems defensive. The point will be explained in detail — for example, patients are
expected to be considerate towards health care providers if the provider has been on duty for 24 hours
and his/her response time is high in 20th hour but otherwise providers must strive to provide best
possible care to the patients.
This statement was modified to read as
To be aware that doctors, nurses and paramedical staff are also human beings and need respite
5.
To make the payment for treatment, wherever applicable, to the doctors /hospitals promptly.
6.
To respect autonomy of doctors and nurses
The Group felt that this statement was too authoritative and changed it to
To respect and accept decisions of the doctors
7.
To treat doctors and nurses with respect
8.
To punctually attend the clinics / hospital / dispensary for treatment at given time
9.
To preserve all records for one’s illness
10. To keep the doctor informed ifpatient wants to change the doctor
11. To know and understand “Patients’ rights’’ and to exercise those responsibly and reasonably
12. To know and understand purpose and cost of any proposed investigation /procedure / treatment
before deciding to accept it
13. To accept all consequences for one’s informed decisions
14. To provide accurate and complete information about his / her own health that is required by the
health provider
15.
To provide accurate and complete information about his / her ability to pay (if applicable) that is
required by the health provider
Points 7-15 were accepted without modifications.
Compiled from:
Pondicherry Declaration on Health Rights and Responsibilities
Manual of Patient’s by ACASH
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Table 4 : Haribhari as a audio-visual medium
Responses (n = 301)
Number
%
Issues
Why is it appealing?
This movie is a family drama, it is excellent
Useful for eradication of disbelieves, good for mass awareness, shows that
women can take their own decisions
Depicts struggles in the lives of women
Helps understand importance of vasectomy
Shows how illiteracy affects life, women can not take decisions
Shows importance of women taking their own decisions
228
76
29
19
14
3
3
8
7
4
1
1
79
23
16
14
11
2
5
26
8
5
5
4
<1
2
Who is the movie for?
Should be screened in wards, for health posts and dispensaries
Should be telecast on Doordarshan
Should be shown in rural area
Should be screened in slum areas, for Muslim communities
A good audio-visual medium, good for all sections of the society
Good for trained paramedical workers not for community
Should be dubbed in Marathi, Gujrati, Telagu etc.
Table 5 : Issues that can be addressed by the health workers
Responses (n = 301)
Issues
Number
%
Family planning and birth spacing
Health education regarding family planning and child spacing
Convince men for vasectomy
Avoiding unwanted pregnancies
155
10
6
52
3
2
Maternal and child health, Reproductive health
Maternal and child health and child morbidity
Sex education
Taboos can be removed
Reproductive health
Maternal and child health and post-menopausal health conditions
Early detection of cancer
Diet during pregnancy
Infertility .
85
25
21
19
18
12
7
3
28
8
7
7
6
4
2
1
General health and health care services
Malnutrition and its consequences including on reproductive health
Guidance regarding better health and treatment at health centre
Information regarding services available at the health posts and dispensaries
18
9
2
6
3
<1
Social issues
Importance of literacy and education to women
Financial independence and decision making
Problems of adolescent girls
Age at marriage should be more than 18
Counselling for prevention of psychological problems
Taking health services to the door step of the needy
Sex of the child is dependent on the father and not on mother
To change attitudes of men towards women
To change attitudes towards girl child
Women's desire should be considered for sexual relationship
77
15
25
130
20
11
5
21
4
1
26
5
8
43
7
4
2
7
1
<1
Issues for health workers
Training of health workers
Health workers can make themselves considerate person
2
1
<1
<1
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Table 6 : Factors affecting women’s decision making ability regarding issues related to their
reproductive health
Responses (n = 301)
Number
%
Factors
Socio-cultural
Illiteracy
Religion, old traditions, old beliefs, cultural pressures
Male dominated culture
Financial dependence on husbands
Pressures from elder family members
Less importance in the family
Ignorance, lack of time for self health, early pregnancy and more number of children
Shyness
Women not allowed to make decisions at childhood
Relationship between husband and wife
Poverty
Lack of or inadequate health information
Lack of knowledge about reproductive health and sexuality
Lack of or inadequate health education
Fear
Limited access to information
Any other
Mentally weak
Note : Multiple response.
147
106
95
91
78
48
43
34
26
11
10
49
35
32
30
26
16
14
11
9
4
3
59
20
12
3
20
7
4
1
2
<1
Table 7 : consequences of women’s lack of control over their reproductive health
Consequences of lack of control over reproductive health
Health related
Women become cancer patients
Health problems, gynaecological problems
Anemia
Maternal and infant morbidity
Deterioration of health condition of mother and children, infections such as TB
Reproductive tract infections / diseases
Unwanted pregnancies
Lack of knowledge about reproductive health organs
Responses (n = 301)
Number
%
102
83
71
69
26
17
2
1
34
28
24
24
9
6
<1
<1
74
44
42
36
24
16
14
11
10
8
25
15
14
12
8
5
5
4
3
3
Social
Early marriage, early motherhood, more children
Early marriage, lack of freedom of choosing life partner
Desire of male child, women forced to leave houses, divorces
Financial dependence on men, mental frustration and ignorance towards health
Poverty and male domination
No control over number of children, inability to refuse intercourse
Mental and physical torture
Family life is affected, women can not live their life as they want
Lack of education
No value for emotions and feelings of the women_____
Note : Multiple-response.
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Discussion related to Proposed Ranking System in sixth QA workshop
the EHO has been open to the idea of introducing a ranking system.
Dr. Jayant Khandare, Medical Officer Health (G/North ward), presented the rating system of health facilities
developed by the Support Group. Given that lack of appreciation of staff affects motivation and the quality of
health services, the support group considered the notion of appreciation based on unit evaluation of health
posts, dispensaries, and later maternity homes and peripheral hospitals.
The MOH cadre is handling the matter to some extent, but without the benefit of a structured appraisal format.
The format presented assigned points to various aspects of infrastructure, personnel, supplies, staff discipline,
aesthetics, and user satisfaction. Minimum expectations were to be decided.
While most of the indicators would be determined by inspection of records of the premises, user/community
satisfaction would be determined through exit interviews, community representatives’ inputs, and the use of a
suggestion box.
Regular reviews at the facility level and application of the proposed ranking system would enable impartial
appreciation at the central level. This could include monthly meetings at the ward MOH level.
Discussion
1.
Complaint follow-up: A mechanism is needed to ensure that each complaint gets followed up: to confirm
that it reaches the proper office, and that action is taken. Some of the questions were: Should this be done
at the facility level or the ward office? Who is responsible for seeing this through? Should the sanitary
inspector collect the complaint box and take it to the ward office? What is the time-frame for follow-up? It
was suggested that details could be worked out by each MOH. In one ward, the MOH has weekly meetings.
2.
The consequence of ranking areas beyond the facility’s control: Who should be held responsible if
shortages of drugs or personnel affected a facility’s rankings? The facility and its personnel could not
always be held responsible; in some cases it may be beyond their control. In such situations, would
rewarding be counter-productive, since it could have a negative effect on people who feel they cannot
improve their grades regardless of their efforts.
3.
Comments were made about specific criteria: The requirement that the facility have a larger number of
repeat users was considered an inadequate measure. The weightage for specific measures was also
questioned: why does wearing uniforms receive such importance? The response was that the ranking
system was based on the group’s field experiences, and the uniform requirement addressed the need for
staff discipline, perceived as one of the more significant barriers to quality assurance. Finally, many of the
measures were activity not coverage indicators. Utilisation will go up if other indicators are being met.
Utilisation rate was thought to be a crucial proxy indicator for a number of quality issues. However, the
support group members felt that they wanted the smaller indicators considered because they wanted to
ensure professional values amongst the staff.
4.
Ranks and grades: It was suggested that marks assigned during the ranking process be converted into
grades for before being made public. For some reason, it was felt that grades would be less threatening
than marks. Most important, the process must be kept transparent or it will backfire and affect staff morale.
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Outline of Policy for Quality Assurance in health care delivery system of the BMC
Vision
According to the BMC Act of 1998, providing health care and maintaining institutes for health care provision is
among the duties of the BMC. This Policy is a commitment of the BMC to the people of the metropolis of Mumbai
for provision of need based quality health care (to those who need it most), irrespective of their ability to pay for
the services. The BMC commits to health care delivery system that ensures professional satisfaction, honours
patients’ rights and continuously strives for improvement in Quality of Care.
Objectives of the Quality Assurance Programme
•
To set clear objectives, standards and indicators for health care programmes and services
•
To outline strategies for implementing Quality Assurance at all levels
•
To establish .a system for regular review of available resources and reallocation of these to meet the
changing needs of the population and the health care providers
•
To encourage a positive work culture that boosts morale, motivates the staff, ensures job satisfaction and
leads to professional development of the employees
•
To establish a health care delivery system that respects the patients’ rights and makes conscious efforts
to educate the patients about these
Strategies for implementing Quality Assurance Programme
•
Defining ‘Quality of Health Care’ and ‘Quality Assurance’ for BMC .
•
Entrusting responsibility of implementation to interdisciplinary teams at facility or ward level with formation
of a committee of senior officers that would review the work at facility levels.
•
Projecting Quality Assurance component from each service or programme and generating awareness by
integrating training for Quality Assurance with ongoing training programmes for various national
programmes.
•
To increase sustainability of the initiative, establishing systems to incorporate the Quality Assurance
aspect into the routine functioning of the BMC.
Steps in implementation of Quality Assurance Programme
I.
Defining ‘Quality of Care’ and ‘Quality Assurance’ for BMC with involvement of all cadres and the users of
the BMC services
A
Perceptions of providers from all cadres and users of the services about ‘Quality of Care’ and ‘Quality
Assurance in Health Care’
II.
III.
B.
Review of policy of the BMC
C.
Review of goals and objectives for each service and programme
Training health care providers in Quality Assurance methods and skills required for these
A
Training teams in specific activities related to Quality Assurance (need based training)
B.
Developing and integrating the module for Quality Assurance with other training programmes
Defining specific objectives (both short term and long term), standards and indicators for each of the
services or programmes
A
Set standards from both client’s and providers’ perspective
B.
Develop measurable indicators
C.
Set attainable goals
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IV.
Develop a system for regular evaluation of performance of services and programmes as per the indicators
and develop a system for regular feedback to grassroot level
Define roles, responsibilities and job descriptions for each cadre
B.
Develop annual work plan for each cadre considering the job descriptions and responsibilities
C.
Regular review meetings at facility, ward / zone, BMC level
D.
Establish a system of supportive supervision
E.
Establish a system for needs assessment and research relevant to Quality Assurance in health care
Rolesand Responsibilities
CHV, ANM, MPW, PHN
•
Participate as a team member in planning Quality Assurance activities at the facility level
•
Implement the Quality Assurance activities
Medical Officer (FTMO / MO i/c — dispensary, maternity home)
•
Assist in developing weekly action plan for the team
•
Assist in implementing the Quality Assurance Programme at the facility level
•
Supportive supervision of the team
•
Liaison between the ward and the team
Medical Officer of Health (MOH)
•
Assist the facilities in planning the Quality Assurance activities
•
Supportive supervision
•
Liaison between facilities and senior officers
•
Liaison between other departments of the BMC
Assistant Health Officer / Deputy Executive Health Officer
•
Review efforts at facility and ward level towards Quality Assurance
•
Offering guidance wherever needed through supportive supervision
•
Policy level decisions to encourage Quality Assurance
•
Liaison between the ward level and the senior officers
•
Encourage building positive work culture
Executive Health Officer
•
Supervise and review formulation of work plan for all levels of facilities
•
Review of activities at ward / zone level
•
Offering guidance wherever needed
Monitoring and implementation of Quality Assurance Programme
(Systems need to be developed after discussion with experts and BMC officers)
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Pre-requisites for a Quality Assurance System for the BMC
Some things that need to be in place before a functional and effective Quality Assurance
System can be established in the BMC, are
•
To define all activities that are part of service provision in terms of objectives, short term and long
•
term goals
To define roles of all cadres in the Public Health Department and job responsibilities regarding
•
each activity
To assigning overall responsibility of reviewing efforts for quality assurance to senior level officer/s
•
To identify systems for implementation of Quality Assurance for each of the activities
•
To set indicators and standards for each component of a service
•
To establish systems for supportive supervision
•
To establish mechanisms for regular monitoring of all services and programmes and for feedback,
•
guidance to those involved in the activity
To develop effective MIS to analyse the data and evaluate the Quality Assurance Programme from
time to time and to establish mechanisms for regular feedback of results of monitoring
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An nexu re 5
Table 1: Key findings from focus Group Discussions to explore information needs
and media preferences
Number of FGDs: With women 6, With men 5
Topics covered in FGD
1.
Awareness about Health Post in the area and perception about health workers.
2.
Media preferences
3.
Health information need
4.
Involvement of local Mandal and NGO in health related activities
Information needs expressed by men and women
Women
Men
• Menstruation related problems
• Gutkha
• Pain in lower abdomen, white discharge
• TB
» STD
• Menstruation related problems
« TB
• Anemia in women
AIDS
• Contraception’s and its side effects
• Contraception’s and its side effects
Views about various media for health education
Street play
Women
Men
• Women do not have time to watch street play
o More than men young boys are watch it.
because of household work.Women feel shy
to come on the street/road to watch it because
all men and young boys are around.
• Six men had seen the street play out of which four
were youths.
• Out of six two of had watched it on TV
Conclusion
Women do not watch street-plays. A group of women suggested that street-play can be arranged for
women in a room or hall. Only three people remembered message of the street-play.
rv
Women
watch programs in afternoon. These include
serials and programs that are family dramas,
women issue based and emotional. At night
apart from mythological serials, women do not
find time to watch TV.
Radio
It was found that in all the FGDs only 2-3 people listened to the specific programs on the radio, which are
mostly informative in nature, related to health, development and legal matters.One of the reasons given by
one man for listening to the program called Arogyam Dhan Sampada was that ‘the program gives answers
to the questions asked by the audience and gives useful information related to health.’
Poster
• Group felt that posters are meant for educated people to read
• Poor people do not have time to pay attention to poster and receive some message out of it.
• Some of the posters are in English that the group thought it is not useful to them. They found it difficult to
figure out the meaning and picture.
• • The group felt that a person should be there to explain the posters.
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Group meetings
Men’s group:
Women’s group:
• Group meetings are secure platforms to talk, clarify
• Women prefer a person (preferably female)
doubts, questions openly.
speaking to them to share the information.
• Group meetings act as a platform for women
• Print media and mass electronic media are not
where they can ask questions, and at the same
useful for illiterate person as their is no two way
time can share their experience.
communication process.
• Knowledgeable resource person would be ideal
• Group meetings will encourage women to talk
as a facilitator.
about their problems otherwise women will never
• Men prefer man to conduct group meetings.
get chance because of their shyness.
Table 2: Key findings of midterm evaluation — interviews with members of IEC Core
Committee
objectives of IEC
•
To create mass awareness’ (Janajagruti) (10).
•
To give information in simple language and in short time (1)
•
To bridge the communication gap (1)
•
For development of self and the community (1)
process of material development
•
Top-down / Hierarchical (9)
in the IEC Cell_______________
•
Not aware (1)
_____
-
Change in the process of
development of IEC material
•
Not needed (2)
Desired changes in the process
•
Involvement of community and health workers
of development of IEC material
•
Material should be people friendly, useful to illiterate and neoliterate
•
Should be pre-tested
Role of IEC Core Committee
•
More use of interactive media for health education
•
To prepare the AAZ materials with community participation to make
the materials people Friendly
•
To reach out to the people through different local media.
•
Core Committee is a platform to voice our opinion about IEC. (One
respondent shared that only through such meetings we can talk in
front of officers otherwise it is difficult to do so.)
Perceived usefulness of IEC
activities of WCHP
•
To suggest and make changes to the IEC Cell whenever necessary.
•
One of the respondents has suggested that the going to the field
helps more than discussions in the meetings. (IEC Cell).
FGD (n = 2)
~
•
•
Can conduct health information session in more interactive manner
Gave need based information (asked the group what information
they wanted)Core Committee (n = 4)
Whether there is a need for IEC
•
Informative discussions
•
7
Learnt about group skills and group dynamics
Yes (9)
Core Committee
Role IEC Core committee could
play
To reduce the communication gap between the IEC officers and HP staff.
It serves as a platform for health care providers to voice their opinions.
Core Committee could effectively supervise and monitor IEC activities
245
1
Women Ccnlrcd Health Project I R e p o r t o f t h e E n d E v a la a t i on
Table 3: Workshops Organised for Members of IEC Core Committee
Duration
Training
2 days2 - 3
September,
1998
Concept of Health
Promotion
Community Radio
October 1998 Workshop
..... days
Training
conducted by
• Socio-economic factors affect • WCHP staff
ing health
• Biological perspective of health
• Health education vs. health
promotion
• Planning of IEC strategies
• Introduction to ‘Community • VOICES
Bangalore
Radio’ as a medium for reach
ing health education to people
Contents
• Process of communication
• Effect of personal biases,
attitudes in communication
• Self assessment and inter
personal communication skills
• Behavioural change
• Body language and visuals
• Principles of participatory
Preparing
4 dayslO - 14
material development
Participatory IEC
April, 2000
materials on RTIs • Creating stories and pictures
based on perceptions of
community men and women
• Pre-testing the IEC materials
• Mass media and group media
Preparing
6 days Two
• Demonstration of various group
batches4 - 6 interactive IEC
media
material on ANC
March 2002
•
Development of material used in
7 - 9 March
group
media-puppets, line draw
2002
ings, flash cards, flannel stories
• Emphasising importance of
pre-testing____________ ___
•
Importance of interactive IEC
Training
in
use
of
2 days14 material
informative
15
broadsheet on RTIs • Training in use of broadsheet
September
on RTI (Mahiticha Bagicha)
‘Mahiticha Bagicha
2001
developed by the Project____
• Development of low cost
Development of
22-26
education media such as line
Low Cost
November,
drawing, flannel stories,
Education
Media
2000
posters, puppets
• Training in using these for
effective health education
• Upgradation of skills required
Workshop on
18-24
to be an effective trainer
effectiveness of
February,
trainer
2002
Effective
1day
Communication
I
December 4,
1999______
Effective
1 day
Communication II
January 14,
2000
August 31 September
7, 2002
September
29 - October
5, 2002
workshop on Group
Media Skills
Development
Trainers’
Effectiveness
Workshop
• External reso
urce persons
• WCHP staff
• External
resource
persons
« WCHP staff
• External
resource
persons
• WCHP staff
• External
resource
persons
• IEC team of
WCHP
• Abhivyakti
• Abhivyakti
Media for
Development
• Effective use of audio-visual • Abhivyakti
Media for
IEC material for conveying the
Development
message to community_____
•
Abhivyakti
• Upgradation of skills required
Media for
to be an effective trainer
Development
246
1
Trainees
17 IEC core
group members
1 CDO (Member
of IEC Core
Committee)
IEC Officer from
WCHPs_______
17 IEC core
group members
17 IEC core
group members
17 IEC core
group members
and NGO
representatives
AHO lECStaff of
IEC Cell21
CDOs, 4 ANMs, 7
PHNs2 CHVs, 3
MPWIEC team
from WCHP(Total
51 participants)
3 CDOs, 14
PHNs3 Social
Work
StudentslEC
team members
1 PHN (IEC Officer
for WCHP and
member of IEC
Core Committee) 1
CHV (member of
IEC Core Committee)
1 PHN (IEC Officer for WCHP and
member of IEC Core
Committee) 1 ANM
(deputedat WCHP
and member of IEC
Core Committee)
IEC Officer from
WCHP
Research Officer
from WCHP
| Women Centred Health Project I Report of the End Evaluation
Table 4: End Evaluation of IEC — FGDs with CHVs for Assessing Effectiveness of
Mahiticha Bagicha
Note : If relevant answer is obtained in response to a question as given in the guideline, the response
is considered without probing.
Training on RTIs using MB
Natwar naqar
2 months prior to
FGD
Kannamwar nagar
Tata Copound
Yari Road
2 months prior 6 months prior to More than 6 months
prior to FGD
FGD
toFGD
Topics covered in the MB _____
Without probing Without probing Without probing 1-2 probes required
Whether probing was required
5
1
Score for accuracy of contents 5
5
Maximum possible score = 5
Symptoms of RTIs in women
Without probing Question not Without probing Without probing
Whether probing was required
9
15
Score for accuracy of contents 20
asked
Maximum possible score = 23
Symptoms of RTIs in men______
Without probing Question not Without probing Without probing
Whether probing was required
10
5
Score for accuracy of contents 10
asked
Maximum possible score = 13
Other topics in which MB______
Without probing
Without probing Without probing Not asked
Whether probing was required
0
Score for accuracy of contents 5
0
—
Maximum possible score =5
Theme in Pushpa’s story______
Without probing Without probing Without probing More than 2 probes
Whether probing was required
required
5
Score for accuracy of contents 5
1
2
Maximum possible score = 5
What did Pushpa do about her condition / symptoms?
Whether probing was required
Without probing More than 2 Question not 1- 2 probes required
5
probes required asked
Score for accuracy of contents 0
Maximum possible score = 5
_________________
5
Do you see situation like Pushpa’s in the community*?
Without probing Without probing
Whether probing was required
Without probing Without
1
1
probing
Score for accuracy of contents 1
1
Maximum possible score = 1
Information not
If women have such condition/ symptoms, what should they do?
More than 2 probed
More than 2 1-2 probes available
Whether probing was required
required
6
Score for accuracy of contents probes required required
15
15
Maximum possible score =17
16
Theme of ‘If I love my wife.. *
Without probing Without probing Without probing More than 2 probes
Whether probing was required
required
5
5
Score for accuracy of contents 5
5
Maximum possible score =5
In the story, what is Prakash asked to do?______
1 -2 probes Question not Question not Without probing
Whether probing was required
10
asked
asked
Score for accuracy of contents required
Maximum possible score =29______
10___________
Do you see situation like Prakash’s in the community?
Without probing Without probing Without probing Without probing
Whether probing was required
5
0
5
Score for accuracy of contents 0
Maximum possible score =5
If men have such condition/ symptoms, what should they do?
,
Without
probing
Without
probing
Without
probing
Question
not asked
Whether probing was required
0
5
15
Score for accuracy of contents 9
Maximum possible score =23
247
Women Centred Health Project I Report of the End Evaluation
If a man has been advised to abstain from sex, but desires sex, what should he do?
Without probing More than two
Question not More than 2
Whether probing was required
probes required
probes required
Score for accuracy of contents asked
5
5
5
Maximum possible score = 5
What is ‘safe sex’?_________
1 - 2 probes Question not | Without probing More than 2 probes
Whether probing was required
required
13
asked
Score for accuracy of contents required
8
9
Maximum possible score =13
What are the causes of RTIs?
Without probing Without probing Without probing More than 2 probes
Whether probing was required
required
13
15
Score for accuracy of contents 15
8
Maximum possible score =15
How can RTIs be prevented?
Question not Question not | Without probing More than 2 probes
Whether probing was required
required
15
asked
Score for accuracy of contents asked
15
Maximum possible score =20
______________
What would happen if the disease is not treated?
Without probing Without probing More than 2 More than 2 probes
Whether probing was required
probes required required
18
Score for accuracy of contents 24
20
14
Maximum possible score =27____________________________ _______
What are the social problems that women have to face if affected by RTis?_______
More than 2 Without probing More than 2 More than 2 probes
Whether probing was required
probes required required
Score for accuracy of contents probes required 27
30
35
37
Maximum possible score =56
248
Women Centred Health Project I Report of the End Evaluation
Annexure 6: Tools used for baseline studies
T-6.1A
Review of health care facilities
Identification No.:
A. Format for Collection of Information on Facility
Please circle appropriate information wherever indicated
Please mention the source : 1. Observation 2. Record 3. Oral information (from whom)
4. Others (specify)•
Information collected by: -(name)
Date/s : (Number of days it took)
Type of Unit
: Health post -1,
Name of the unit:
Address :
Post Partum Centre - 3.
Dispensary -2,
Locality :
Ward :
Pin code :
Phone number:
I. Physical structure of the Unit:
1. Whether independent unit in terms of structure (building):
2. Year of establishment:
3. Ownership of the building : 1) Owned by BMC
4. Does it have compound wall ? Yes -1, No - 2.
5. Number of floors:
6. Total floor space (sq. ft):
7. Number of Rooms :•
8. Describe what is each room used for:
Source:
9. Is there a rest room room for the staff?
1) Yes 2) No.
10.1s separate room for meetings ? 1) Yes 2) No.
11. If No separate room is there, where are the meetings held :
Source:______ _______ ____________ _______________
249
1
2) Rented 3) Any other : (specify)
| Women C entred Health Project I Report of the End Evaluation
12. Furniture in the unit:
Sr. No ______Particular_____ Sanctioned
Table (big size)
1.
Table (small size)
2.
Chair (with arms)
3.
Chair (without arms)
4.
Folding chairs
5.
Revolving stools
6.
Examination table
7.
Steel stool/wooden
8.
Steel benches
9.
Rack (Steel )/wooden
10.
Bed screen (3 folds)
11.
Wash basin with tap
12.
Instrument cabinet
13
Wall clocks
14.
Cupboard
15.
Ceiling fan
16.
Pedestal fan (table fan)
17.
Cash Box .________
18.
In position
Functioning
13. Toilet?
1)Yes 2) No.
14. If there are toilets available, how many
15. Toliets cleaned ? 1) Yes 2) No.
15b. If yes, period :
-----
Source:
16. Do the staff have a separate toilet ?
1) Yes 2) No
17. Source of water: 1) Tap 2) Others (specify)-----------------------------------18. Timing of water supply :------------------------------------ -----------------------------19. Is there Electricity ?
1) ^es 2) No
20. Is there an examination room ? : 1) Yes 2)
2) No.
No.
If yes, area (sq.ft):
21. Examination room has : 1) Privacy
2) No privacy .
22. How are the waste disposed ? : -1) Burnt
2) Incinerated
4) Any other (specify)
3) thrown into Common garbage
23. Storage place : 1) Separate storage for drugs/supplies/records .
'2) Storage space shared with consultation or reception rooms
3) No storage space
-J?
II. Human Resource
24. Staff composition of the unit
S.No Staff____________ Sanction
Doctor
1.
PHN
2.
ANMs
3.
Female field worker
4.
MPWs
5.
CHVs
6
Pharmacist
7.
X-ray techn.
8.
Lab techn.
9.
Attendant
•
10.
In Position
250
Remarks (if any)
1
| Women Centred Health Project I Report of the End Evaluation
11.
12.
13.
14.
15.
16.
17.
Co-ordinator
Clerk
Dresser
T.B.O
Malaria investigator
Sonologist
Source:
25. Characteristics of the staff
S.No Staff (write the name)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Sex
Qualification
Doctori
Doctor2
PHN
ANM1
ANM2
ANM3
ANM4
ANM5
ANM6
Female field worker
MPW1
MPW2
MPW3
MPW4
Pharmacist
X-ray techn.
Lab techn.
Health Attendant
Co-ordinator
Clerk
Dresser
T.B.O
Malaria investigator
Sonologist
Source:
26. If the unit is a Health Post obtain the following information:
- Number of CHVs residing in the locality:
Source:
_____
III Services Provided at the Unit
27. List out the type of services provided at the unit:
I 251
1
Length of
service at
this unit
Residence
| Woiyen Centred Health Project I Report of the End Evaluation
....
''
"
"'
'
......
i
Source:
28. Working Hours of the Unit
29. Service Provision (mark the day for a particular service and number of people served during
the preceding week & please record the information from the register).
5. No Service
Imm. at unit
1.
2
Imm. at area camp
OPD
3.
4.
Home Visit
5
IEC activities
6.
Monday
Tuesday
Wednesday Thursday
Friday
Saturday
30. Issues covered in the IEC activities during the last one month : (refers to group activity)
31. Does doctor attend the IEC activities in the area ? : 1 - Yes ( Often/occasional)
2-No
32. During last one month how many of the following cases were followed up by different staff?
• This refers to those cases which were followed up after the services were recieved by clients. If in
the last one month the cases were not followed find the reasons and write them below this table.
S.No Staff
1.
2.
3.
4.
Family Immunization
Planning
ANC
Water
born diseases
ANM1
ANM2
ANM3
ANM4
MPW1
MPW2
MPW3
MPW4
Doctor
Co-ordinator
Source:
33. Is there a pathological lab ? 1) Yes 2) No 3) NA
34. If yes, type of tests conducted :
35. If No, where is the referral made (places where patients are sent) ? :
Source:
252
1
VPD
Other
| Women Centred Health Project I Report of the End Evaluation
36. In case of emergency, where are the patients referred to ? :
Source:
37. Referral system practiced at-the unit (how is referral carried out orally/written/documented )?
Source:____________________________________
IV . List of Equipments, Drugs and Supplies at the unit
38. List of Equipments :
{where ever not applicable, write NA}
S.No Items
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Avail
-able
Sanct
-ioned
Work
-ing
Foetoscope
BP Appratus
Stethoscope
Thermometer (body)
Tongue Depresser
Reflective Mirror
Hammer
Measuring tape
Weighing scale (adult)
Weighing scale (child)
Scalpel
Round body needles
Cutting needles
Sutures and ligatures
BP holder
Scissors
Refrigerators
Dial thermometer
Sterilizer
Syringes
BCG vaccine syringe
Autoclave
Vaccine carriers
Ice pack
Resuscitation equipment
Suction machine
MCH kit (delivery)
Slides
Test tubes
Spirit lamp
Unsticks
Forceps
Artery forceps
Speculum (Gynaec & Obstet)
l
253
I
Remarks (if any)
I Women Centred Health Project I Report of the End Evaluation
S.No Items
4
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
Sanct
-ioned
Avail
-able
Work
-ing
Remarks (if any)
Valselum (Gynae & Obstet)
Ovarian sound instrument
Sponge holder
A. P. retractor
A.V. retractor
Anesthetic Vaporizers
Bowls
IV Stand
IV fluids and giving sets
Cannulas
Steel drum
Kidney tray
Mackintosh.
Operation table
Enamel tray with cover
Hamometer
Laproscope
Source:
39. Drugs available at the Unit
a) Tablets
5. no
1
2
3
4.
5
6.
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
Tablets_____________
Paracetamol
Brufen
Iron folic acid (mother)
Iron folic acid (child)
Calcium
B.Complex
Vitamin C •
Tabvitamin A&D
Multi-vitamin
Balargan
Beladona
Duvadinal
Methargin
Flagyl
Doxycyllin
Amphicillin
Erythromycin
Terramycine
Cotrimaxazole
Chloroquine
Primaquine
Isonex
Pyrizinamide
Ethambutol
Dulcolax
Mebex
Piprarcizine citrate
Antacid or Gellucil
Liv 52
Avil
Asthalin
Calmpose
Available
Sanctioned
Vaginal Pessries
254
1
Out-dated
| Women Centred Health Project I Report of the End Evaluation
Source:
b) List of Syrups :
S.No Syrup
Cough Syrup
1
Vitamin A Syrup
2
Paracetamol Syrup
3
4
Flagyl Syrup
Eritromycin
5
Ampicillin
6
Multi-vitamin
7
Avil
8
9
Ibugesic
Phenargan
10
Sanctioned
Available
Out-dated
Sanctioned
Available
Out-dated
Sanctioned
Available
Out-dated
Source:
c) Local Applicants:
S.No Local Applicant__________
Iodine
1
Tincture Benzoin
2
Gention violet
3
Glycerin Borax
4
Soframycin eye/ ear drops
5
Benzyl benzonate
6
Lotion calamine
7
Hydrogen Peroxide
8
Chloromycetin eye applicap
9
Acriflavin lotion
10
Soframicine ointment
11
Turpentine linimente
12
Source:
d) List of Injectables :
S.No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Item
Streptomycin
Soda-bi-carb
Dexamithazone
Avil
Hydrocdrtizon/Effcorline
Ineferon
Fortwin
Adrenaline
Coramine
Pethedine
I.V. fluids (type)
Calmpose
Xylocaine
Water for injection
Source:
255
1
[ Women Centred Health Project I Report of the End Eva 1 uation
e) List of Vaccines
S.No
1.
2
3
4
5
6
7
8
Vaccines
DPT
TT
BCG
Polio
Measles
DT
Thyphoid
Cholera
Sanctioned
Available
Sanct
-ioned
Work
-ing
Out-dated
Source:
40. Supplies
S.No Supplies
1
2
3.
4
5
6
7
10
11
12
13
14
15
16
17
18
19
20
21
22
19
20
21
22
Avail
-able
Remarks (if any)
Copper - T
Oral Pills
Condom
ORS packet
Sticking plaster
Gloves
Bandage
Gauze piece
Sterile pads
Cotton swabs
Savlon
Spirit
Ether
Soap
Torch
Bucket
Bed sheet
Towel
Stove
Cooker
Audio-visual equipment
IEC material
Ice-cube tray
Cutter file
Source:
V Records and Registers kept at the unit
Name of the Record book/
Register_____________
Eligible Couple
Child Register
Baseline
Follow-Up ANC & PNC
Immunization (Area)
Immunization (HP)
Family Planning
ANC Camp/Day
Post Natal Care
Frequency of
Who
Maintains Reco rding/Updating
256
I
Submitted To
Whom
j Women Centred Health Project I Report of the End Evaluation
r•
&
>.
K
Birth & Death Register
Complication Register
Disease Surveillance
Temperature Chart
Programme Book
Visit Book
Monthly Report
Daily Diary
Nirodh (Stock Register)
Oral Pill (Stock Register)
Copper T insertion
Copper T removal
Sterilization register
Pana - M
Pana - C
ORS register
Vitamin A
Successful motivation
Daily Report Book
R15 R16 •
Health Talk Register
Review register
Stock register
Immunization report
Vaccine report book
Cleanliness project file
Output-dispatch
Sterilizer book
Syringes book
VPD register
Injection register
Tablet register
IEC stock book
Dead stock book
Stationery book
Impress book
CHV report book & muster
Priv. Med. Practioner report
Circular file
Cross check book
Concession register
Referral book
Icentive book
Indent book
Acute respiratory register
Source:
.4
3"
j*
VI Meetings held at the unit
41. List out the details of Meetings held during last one month
Date/Timings
Purpose
Participants
Topic
Source:
|
257
1
Place
| Women .(j'cnlned Health Project ~| Report of the End Evaluation
T-6.1B
Review of health care facilities
Identification No.
B.
FORMAT FOR THE COLLECTION OF INFORMATION ABOUT THE COMMUNITY
{For each locality separate sheet is to be used}
. Date/s:
Information collected by:
Ward Name :
Area:
.__________________
1. Locality name :
2. Main industrial unit in the locality:
3. Type of huts :
4. Approx. No. of Households:
5. Nearby Market place:
6. Bus stop /railway stop :
2) No.
7. Ration shop in the locality : 1) Yes
8. Space for meetings in the area ? : 1) Yes 2) No.
9. If there is space for meeting, write the place
Type of people
1. Population (No):^
2. Main language group :
3. Main religious group :
4. Main occupation of women :
Leaders/social workers
1. Leaders :
2. Social workers in the locality:
3. Political party favoured by the local people :
Local Organizations (Number)
Local Organization_______ Number
Mahila mandal
Yuvakmandal
Sports club
Aganwadi
Ganesh mandal
Worker’s welfare association
NGO
Others (specify)__________
Activities carried out by the organizations
Source:
Facilities available in the Community
14. Education
Number
Type of school
Ownership
Source:
258
| Women Centred Health Project I Report of the End Evaluation
15. Health Infrastructure
List out the number of private health Providers :
MBBS---------, MD-, Gynaec--------------- , BDS (Dental) —
Ayurved-------- Naturopath--------- , Unani--------- , Tantrik
Source:
, Skin & VD------ , Homeo
—, Others.
List out the number of Private Medical Infrastructure available in the locality:
Pathological Lab-------- , Pvt. Maternity Home------------- , Pvt. Nursing Home------,
Ambulance Facility--------- ,
Source:
Pharmaceutical Shops------ ,
Others :--------------- .
Protocol
• Please fill in pencil
• Please write clearly and do not scratch
• Do not give this format to anyone other than the project team.
• Please circle the relevant information
• Please write the source of information
• Please use one format for one facility/unit
• Please write postal address and approach
• If the floor are mopped and toilets and dustbins are cleaned everyday tick the acceptable
standards.
Remarks : Those on leave or training write number
j
259
1
Women Centred Health Project I Report of the End Evaluation
T-6.2
A study of health care providers’ perceptions and attitudes towards
women’s health and quality of care provided by the municipal health care facilities
CONSENT FROM THE PROVIDER
As you know that the BMC has undertaken the Women Centred Health Project (WCHP) to pilot interventions
for improvement in the quality of care of health services provided through Health Posts, Dispensaries,
Post Partum Centres, Maternity Home and General Hospitals located in the two wards of the city. In
order to facilitate the experiment, there is need for a baseline study (research) for which a comprehensive
plan for data collection from various sources has been developed. One of the major sources of the
required data are the.staff like you working in the BMC health facilities. Only you know best, the work you
have been doing in your facility. Therefore, only you are in a position to say correctly about your work.
The WCHP requests you to extend your full cooperation in providing the information required from you.
The WCHP would like to assure you that the information obtained from you would be kept confidential and
anonymous and would be used only for research purposes. However, before you provide any information,
the project would like to seek your consent towards your willingness for the same. The information
required are related to your Education, Length of service, Activities being cerried out, Perception of
women’s health and Quality of care, Training needs, etc. If you are willing to provide the information,
please fill in the consent form given below and hand it over to the person seeking information from you. If
you would like to ask any questions about the research please feel free to ask.
Thanks.
CONSENT FORM
I,
with (facility)
, working as
at (place)
understand the purpose for which the information are being collected by the WCHP. I am
giving my consent to make use of the information provided by me.
Date:
Signature:
TOOL TO OBTAIN DATA ON PROVIDERS’ PROFILE, PERCEPTION, ATTITUDE, ETC.
1.0.0. Personal data:
1.1.0. Name of Facility
1.2.0. Age
1.1.1. Type of Facility
1.4.0. Marital status
1.3.0. Sex:
1.5.0 Place of usual residence
1.6.0. Time taken to reach from residence to place of work.
1.7.0. Education
260
’
Women Centred Health Project I Report of the End Evaluation
2. 0.0. Job details:
2.1.0. Total experience on job till date (years)
at this unit since
2.2.0. Currently working as a
years.
2.3.0. Present activities with frequency and time spent.
Sr.No.
1.
2.
3.
4.
5.
6.
7.
8.
Frequency
Present activities
Time spent
3.0.0. Perceptions of Women’s Health:
3.1.0. Types of ailments most commonly reported by the female patients?
A.
B.
C.
D.
E.
F.
3.2.0. Which ailments do you think are not reported by most women?
A.
B.
C.
D.
3.2.1. Why?
3.3.0. What are the reasons which prevent women from being healthy? List them in order of importance.
A.
B.
C.
D.
3.4.0. What timings are most convenient for seeking health services from the BMC health facilities by
Women
Men
3.5.0. Would you be able to work as per their convenient time?
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[ Women Centred Health Project I Report of the End Evaluation
4.0.0. Quality of health services :
4.1.0. What problems do you face in carrying out the activities with regard to the areas mentioned in the
following table?
No.
1.
Infrastructure
2.
Staff
3.
Community
Others
4.
Problem/s
Area
a. space
b. furniture
c. electricity
d. water
e. storage space
f. others
a. composition
b. co-operation
c. co-ordination
d. attitude towards work.
e. interpersonal relationships.
4.2.0. What are the problems faced by you while rendering the following services ?
Problems
Services
No.
1.
A. N. C.
2.
Intra natal services.
3.
P. N.C.
4.
Family Planning
5.
Immunization
6.
Gyanaec.
7.
Curative
8.
9.
Laboratory
Others
4.2.1. How can these problems be minimised?
4.3.0. Referral: ( Notfor CHV and Pharmacist)
ST.No.
Kind of cases
reffered
Reason/s
for referral
Place Procedure
where followed for
referral referral
Feedback
received
from the
refferral
institutions
1.
2.
3.
4.3.1. What are the problems faced by you / your patients when referred ?
I
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4.3.2.What measures could be taken by the BMC to improve the referral system?
4.4.0. What are your suggestions to improve the quality of Health Services especially for Women,
through your Facility ?
4.5.0.When will you say that the services provided by health care facility is good ?
5.0.0. Out-reach Services (to be asked from the Health Post staff and CHVs):
5.1.0. What are the advantages of outreach services?
5.2.0. How could the quality of outreach services be assessed (indicators)?
A.
B.
C.
D.
5.3.0. How to know the people’s opinion about the quality of the outreach services?
6.0.0. Training Needs : [ For all staff]
6.1.0. Training information
Useful/Not useful
Training received
I
6.2.0. Do you think you need further training to carry out your work in a better way? Y/N
6.2.1. if yes, in which areas (subjects/topics)
A.
C._____________________________
E.
B.
D..
F.
7.0.0. Women’s Health and Quality of Care.
If the respondent is a doctor (The respondent is to read each statement at a time and tick only one
response category against it which is closest to his/her opinion.) If the respondent is other than a doctor
(The investigator is to read out the statements to the respondent and his/her response is to be marked
under one of the five categories of the responses)
Note : Health Providers, Workers, Staff are the same.
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Statement
Fully
Agree
1. Women suffer more health problems than men.
2. Women are less capable than men to make
decisions in the family.
3. Men should take more responsibility for
contraceptive use.
4. More privacy is needed for physical examination
of women.
5. Women have more difficulties than men in
protecting themselves from STDs.
6. Health providers should show more respect for
clients especially poor ones.
7. Women should be examined by the female
doctors only.
8. All women related health services should be
provided at one place in a locality.
9. Health providers have an important role to play in
addressing domestic violence.
10. Quality of the BMC health care is good.
11. Husband has right to sex with his wife without
her wish.
12. Health workers should help couples to make joint
decisions about family planning.
13. Quality of BMC health care cannot be improved.
14. Users will always complain about the quality.
15. There is need to improve quality of BMC health care.
16. Women suffer from health problems because t
hey are ignorant of their own health needs.
17. Training is needed to improve the quality of care.
18. Health workers should work more with clients
to develop appropriate information materials.
19. Referral system is imp. for improving quality
of health care
20. Health workers learn a lot from listening to the
knowledge of illitereate clients.
21. Staff satisfaction is crucial for good quality of care.
22. Information provided about infertility is often very
poor.
23. There is no need for a special provision to take
care of women’s health problems.
24. Staff are adequately trained to improve quality of
care.
25. Suggestion/complaint book should be kept in the
facility.
26. TL camp is the best method to fulfil the FP
targets.
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Partly Can’t
Agree Say
Fully
Partly
Disagree Disagree
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T-6.3A
Exit interviews of users of municipal health services
(OPD user / client of municipal health care facilities)
Identification Code:
1.
EXIT INTERVIEW WITH OPD USER/CLIENT OF THE BMC HEALTH FACILITIES
(Women Centred Health Project, Vile Parle, Mumbai)
The objectives of this Exit Interview are to elicit user’s/client’s (1) knowledge about the services
available at the BMC’s health units, (2) level of satisfaction, (3) costs incurred on availing these facilities
and (4) suggestions for improvement in services.
Consent of the Respondent:
The BMC intends to improve the quality of its health services, for which some information are needed as
how do the users like you find the services, how much time and money are spent, etc. Can you spare few
minutes and respond to our queries. Your responses will be kept confidential and used for research only.
Instructions:
Sections I, II, & III, are to be completed before the user goes to meet the service providers
Section IV to be completed immediately after the user receives the services.
Section : I: Identification Details. (to be filled in advance by the investigator)
1.
Date:
. 2. Time:
. 3. Ward No.
. 4. Facility:
Section II: Purpose of visit and awareness of health services available at the present facility.
(In case the user is not in a position to answer, the details are to be obtained from the person
accompanying her/him).
Time of arrival of the user at the unit
Time when the user is about to leave the unit:
1. Purpose of the visit:
2. Is anybody accompanying you today ? YES
3.
NO. 2a. If YES, who:
Prior to coming here, what did you do towards solving the present problem?
d HOME REMEDY d GONE TO OTHER BMC UNIT d PRIVATE DOCTOR
d CAME HERE DIRECTLY {go to 04} d OTHERS (specify)
3b. How much costs (Rs.) did you incur before coming to this facility?
(i) Doctor’s fees :
(ii) Drugs :(iii) Diagnostic tests :
(v) Other costs (specify):(vi)Total Expnediture
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| Women Centred Health Project I Report of the End Evaluation
f •
4. Do you know what health services are available here? {Tick mark}
4.1. If response is Yes / No in the coloumn, ensure how the respondent knew it ?
4.2. At VN. Desai Hosp., about all listed services except Health Education are to be asked
Service available______________
Treatment for minor illnesses
T. Blood test
B. Urine test
Diagnostic
C. Sonography
test
D. Others
Yes
Don't know
No
H/D/P
(specify)
Maternity
related ’
T. ANC
B. Abortion
C. Delivery
D. PNC
Obstetric/Gynaecological
Child immunization
Paediatric services
Dressing of minor accidents
Postponment of menstrual cycle
Family Planning methods
T.B treatment
Referral
Health Education
I Others (specify)
H = Health Post D = Dispensary
P
H/D/P
H/D/P
H/D/P
D
H/P
H/P
H/D
H/D/P
H/D/P
H/D/P_______
P = Post Partum Centre
5. For what purposes do you visit this facility?.
Section III: Profile of the Client (In case the client is not in a position to answer, then
get the details about the client from the person accompanying her/him).
Client’s sex :
•M • F
1a. Age (completed years/months): ----------------------1.
Respondent
’
s
sex
:
•
M
•
F
2a. Age (completed years): - -------------------------------2.
Distance
from
your
home:
•
<10min
• 10-20 min • 20-40 min • 40-60 min • 60min+
3.
Mode of travel & travel costs incurred
Mode of travel
Auto/Taxi
Bus
Walk
JOURNEY
3a.
Train
Costs incurred
Total (Rs.)
To the facility
To residence
4. Mother Tongue: • Marathi • Hindi • Urdu® Tamil • Telugu • Kannada • Gujarati
• Malayalam • Konkani • Bengali • Others(specify)----------------5. Marital status : • Unmarried • Married • Separated •
• Destitute
Widowed • Divorced
6. Education Level: • Non-literate • Literate • Std 1-4 • 5-7 •8-10 •
• Tech. Course • Literate
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• Women Centred Health Project I Report of the End Evaluation
7.
8.
10.
Years/months of stay in the present locality (yr/months):
Number of family members: 9. Number of earning members :
Occupation of the earning members:
____________________________________
11.
12.
Occupation of the client: .
Total monthly income of the family:
Section IV :
Process involved for Seeking Services, level of Satisfaction &
Suggestions for Improvement in the quality of care at this unit:
1.
What did the doctor/nurse do during examination ? (multiple choice)
(1) enquired about symptoms
(2) examined minimally(used stethoscope/felt pulse)
(3) conducted detailed physical examination (mouth/eyes/gynaec check-up)
(4) gave prescription (drugs/injections/tests) (5) Informed about diagnosis.
(6) Asked me to come again for a follow-up (7) Any other (specify)
2.
Did you have privacy during examination ?
• YES
• NO
3.
Were there any questions which you did not ask ?
Did you want to ask any question?
• YES
• YES
• NO {go to 04}
• NO
• NA
3a. If YES, what made it difficult to ask those questions ?
4.
A.
B.
C.
What did the Doctor/Nurse tell you/the person accompanying you :
About details of illness:
____________
About the advice on treatment:
About other aspects :
• NO
• YES
5. Were all the prescribed medicines provided at the facility?
& have to buy
5a. If NO, number of medicines provided at the facility
• YES
6. Were you given instructions as how to take the medicines ?
• NO
6a. If YES in Q.6, instructions were given • VERBALLY
• WRITTEN • BOTH
6b. Did you understand these instructions?
• YES
7.
• NO
If the doctor recommended a iagnostic test, (i) tests to be done at facility
(ii) referred to private doctor(iii) referred to BMC :
(iv.) N.A
8.
How much time you waited today to seek services? • TOO LONG
8a. Is the working hours of this unit for you
• CONVENIENT
• NOT MUCH
• INCONVENIENT
8b. If INCONVENIENT, what should be the convenient working hours?.
9.
Client’s satisfaction with behaviour, advice and treatment given by providers today ?
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Satisfied
Could be Unsatisfied Why do you feel so
better
I. Personnel Behaviour
1. Doctor
2. Regn. Clerk
3. Nurses/PHN
4. Pharmacist
5. Attendant
6. Lab techician
7. Other (specify)
II. ADVICE
10. Will you visit this facility next time you have any health problems ? • YES • NO
10a. If YES, why?
10b. If NO, reasons for why you would not use this facility?
• No diagnosis or treatment provided for illnesses among adults.
• No diagnosis treatment provided for childhood illnesses.
• Requires repeat visits for medicines & immunization.
• Staff members shout/show disrespect.
• It is closed in the evening when I get time
• Others (specify)
*
11. What should be done to improve the services at this unit?
Consent of the respondent for follow up:
Can we meet you again to find the result of the current treatment? • YES
If yes, please give your complete address:
Name of the investigator & Signature:
Spot checked by :
Edited by :
268
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• NO
I Women Centred Health Project I Report of the End Evaluation
T-6.3B
Exit interviews of users of municipal health services (Mother /father of the child
seeking imunisation services at municipal health care facilities)
Identification Code:
B. EXIT INTERVIEW WITH MOTHER/FATHER OF THE CHILD SEEKING IMMUNIZATION SERVICE
AT BMC HEALTH FACILITIES
(Women Centred Health Project, Vile Parle, Mumbai)
*
The objectives of this Exit Interview are to elicit user’s/ client’s (1) Knowledge of the services available at
the BMC’s health units, (2) level of satisfaction, (3) costs incurred on availing these facilities and (4)
suggestions for improvement in services.
Consent of the Respondent:
The BMC intends to improve the quality of its health services, for which some information are needed as
how do the users like you find the services, how much time and money are spent, etc. Would you like
to spare few minutes and respond to our queries. Your responses will be kept confidential and used for
research only.
Instructions
Sections I, II, & III are to be completed before the child is immunized.
Sections IV are to be completed after the child is immunized.
Section : I: Identification Details (to be filled in advance by the investigator)
I.Date:. 2.Time:
4. Name of the Facility :
. 3. Ward No.
Section II : Immunization status of the child (Answers to be obtained from either the mother or the
father or an adult member of the.child’s family accompanying the child).
1. Age of the child brought for immunization (months):
2. Sex :
3. Birth order of the child :
4. For which dose/s of immunization, the child has been brought? Circle the appropriate
dose/s.
A. BCG
B. POLIO
C. DPT
i
0
i
I
II III Booster I
II III Booster I
D. MEASLES
E. DT
I
I
II
5. Do you know what health services are available here other than child immunization?
(Tick mark}
5.1. If response is Yes / No in the coloum, ensure how the respondent knew it ?
5.2. At V. N. Desai Hosp., about all listed services except Health Education are to be asked.
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| Women Centred Health Project I Report of the End Evaluation
Service available__________
Treatment for minor illnesses
Diagnostic
Test
<
4-
Maternity
Rated
Yes
No
Don’t know
H/D/P
D/P
A. Blood test
B. Urine test
C. Sonography
D. Others (specify)
A. ANC
B. Abortion
C. Delivery
D. PNC
P
H/D/P
Obstetric/Gynaecological
H/D/P
Child immunization
H/D/P
Paediatric services
D
Dressing of minor accidents
H/P
Postponment of menstural cycle
H/P
Family Planning methods
H/D
TB treatment
H/D/P
Referral
H/D/P
Health Education
Others (specify)______________
H = Health Post
D = Dispensary
P = Post Partum Centre
6. For what other purposes do you visit this facility?
Section III: Profile of the Mother/Father/Relative (Respondent) of the child:
1. a Client’s sex
: • M • F
2. a Respondent sex: • M • F
1 ,b Age (Yr / Months):
2.b Age (Years) ::------------
3. Distance from your home: • 10min • 10-20 min • 20-40 min • 40-60 min • 60min+
3a. Mode of travel & travel costs incurred
JOURNEY
Auto/Taxi
Mode of travel
Costs incurred
Walk
Train
Bus
Total (Rs.)
To the facility
To residence
4. Mother Tongue: • Marathi • Hindi •Urdu • Tamil eTelegu •Kannada • Gujrati • Malayalam
• Konkani • Bengalee • Others(specify)
5. Marital status ;
•Unmarried • Married •Separated
•Widowed
• Divorced dDestitul
6. Edu. status : • Non-literate ©Stdl-A •5-7 •8-10 ©lO-^ •College •Tech course
7. Years/months of stay in the present locality (yrs/months):
8. Number of family members : 9. Number of earning members .----------------- -10. Occupation of client:-------------------------------------------------------------------------- —-----------11. Earning members occupation :
_______________________
12. Total monthly income of the family:
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[ Women Centred Health Project"! Report of the End Evaluation
Section IV : Procedure followed for Seeking Services :
1. What did the staff tell you before immunizing the child?
2. Problems, if any, while the child was getting immunized?
3. What did the staff do to tackle the problems?
4. What did the staff tell after immunizing the child?
5. Did the doctor/nurse tell you when the child would need another dose ? • YES
• NO
• YES •NO
6. Do you have any health problem ?
6a. If YES, what is the problem :
6b. Did you talk about your health problem with doctor/nurse ?
• YES
• NO
• YES
• NO
6c. If NO,why?
6d. If YES in Q6b, were you problems addressed to ?
6e. What advice/treatment was given ?
7. Client’s satisfaction with the behaviour, advice and treatment given by the providers today.
Satisfied
Could be Unsatisfied
better
1. Personnel Behaviour
2. Doctor
3. Regn. Clerk
4. Nurses/PHN
5. Pharmacist
6. Attendant
7. Lab techician
8. Other (specify)
II. ADVICE
2. What should be done to improve the services at this unit?
Name of the investigator and signature:
SPOT CHECKED BY:
EDITED BY :
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| Women Centred Health Project I Report of the End Evaluation
T-6.3C
Exit interviews of users of municipal health services (User of the outreach services
of the municipal health posts)
Identification Code
C. INTERVIEW WIT ‘ USER OF THE OUTREACH SERVICES OF BMC HEALTH POST
(Women Centred Health Project, Vile Parle, Mumbai)
The objectives of this Interview are to elicit user’s/client’s (1) knowledge about the outreach services
provided by the health posts, (2) level of satisfaction from the use of the services, and (3) suggestions for
improvement in the services.
Consent of the Respondent:
The BMC intends to improve the quality of its health services, for which some information are needed as
how do the users like you find the services. Can you spare few minutes and respond to our queries. Your
responses will be kept confidential and used for research only. YES/NO
Section : I: Identification Details. (to be filled in advance by the investigator)
1. Date of interview:. 2. Time of interview:
3. Name of the locality and the Health Post :
Section II: Awareness of the health services provided by the Health Post.
2.1 Is there a Health Post located in this area ?
(The investigator to check correctness of the identification)
2.2 Did any health worker visit your family during the
last one month
last three months
YES/NO
YES/NO
2.3 If Yes, who was he/she? (Name/designation):.
2.4 What did he/she do/say during the last visit?.
2.5
How much time did he/she spend approx, with your family during his /her last visit? (Min/hour)
2.6 What time of the day did he/she visit your family ?
2.7
Was the time of his/her visit to your family convenient to you?
2.7a. Give reasons?
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| Women Centred Health Project I Report of the End Evaluation
2.8. What services are provided by the health workers when they visit home?
(explore how the respondent knew it)
No
Yes
_____ Service provided_____________
Treatment for minor illnesses
Obstetric/Gynaecological
• ANC
• PNC
• MTP/Abortibn
• Distribution of Iron folic tablets
Refer white discharge cases to HP/Disp
Postponment of menstural cycle
Family Planning methods
• Oral Pills
• Condom
Paediatric services
• Child immunization at HP
• Child imm. in the locality/ camp
• Growth monitoring
Referral to HP/ Other hospitals
TB treatment
Other activities
• Health education
• Group meeting,
• Family Planning education,
• ORT
• Nutrition education
Cleanliness
Disease surveillance in the community
Others (specify)
Don’t know
2.9 Have you ever discussed your health problems with the health worker visiting your
family?
YES/NO
2.9a If NO, why?
2.9b If YES, which of the following services did she/he provide ?
• ADVICE/COUNSELLING
• MEDICINE
• REFERRAL
2.10 What benefits do you get from her/his visit to your family?
2.11 Are you satisfied with the health worker with regard to
a) the information provided ?
why ?
b) the advice given ?
• YES • NO
• YES • NO
why ?
• YES • NO
c) the frequency of visit?
why ?
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[ Women Centred Health Project I Report of the End Ev a I u a t i o n
d) her/her behaviour?
why ?
• YES • NO
2.12. Your suggestions, if any, to improve the services which are needed by the community
Section IV: Profile of the Respondent:
3.1a. Respondent’s sex : • M • F
3.1b. Age (completed year).
3.2 Mother Tongue: • Marathi • Hindi • Urdu • Tamil eTelegu • Malayalam
• Kannad • Gujrathi • Konkani • Bengalee • Others(specify):
3.3. Educational level : • Non-literate • Literate • Std 1-4 • 5-7 • 8-10
• College • Technical course
3.4a. Marital status : • Unmarried • Married
• Destitute
• Separated • Widowed • Divorced
3.4b. (If other than unmarried).
How many children have been born to you? Total
3.5. Years/months of stay in the present locality:
3.6. Type of family:
3.7
• 10-12
Number of family members :
3.8a Main occupation of the respondent:
3.8b Occupation of the other members of the family:
3.8 Total monthly income of the family:
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T-6. 4
Exit interviews at gynaecology out-patient clinics at health posts
Women Centred Health Project
Public Health Department
Brihanmumbai Municipal Corporation
Exit Interviews of Women Users of Gynaecology Clinics at Health Posts
December 2002
Instructions for the interviewer:
Women in pain or those women who are in distress (not in position to speak or are unable to wait) should
not be asked for interview. Do not begin the interview without seeking consent. It is important to sign after
seeking consent.
The woman was informed of the following and her consent was sought for interview I am
. We are conducting a survey to understand possibilities of improving the services
provided through this OPD. We wish to know about your experiences regarding this OPD. We would like
to ask you a few questions. It will take around 15-20 minutes for asking these questions. Will you talk
to us? Will you give us the information? Information given by you will be kept confidential and will not be
misused.
(Allow the woman to think and say yes or no. If she refuses, request once again. If she refuses ask the
next patient / woman. If the woman agrees for the interview, say —)
If you wish to discontinue the interview please let me know. We will immediately stop the interview.
Signature of the interviewer
Health Post
2. Age:
Years
Date
1. Name
3. Marital Status
Married
Widow
Deserted
Not asked
1
3
5
95
Unmarried
Divorced
No Response
Sr.No.
2
4
99
4. Reason for coming to OPD
5. Duration of symptoms? Days, Months, Years
Not asked
95
I No Response
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| Women Centred Health Project I Report of the End Evaluation
6. Have you taken any treatment before coming to the clinic?
Yes_____
1
No
Not asked
95
No Response
6.1
Did you take any home remedies before coming to the clinic?
Yes
No_________
Not asked
95
Not Applicable
No Response
99
2
99
2
98
(If response to 6.1 is ‘yes’; ask 6.1.1,6.2)
6.1.1 What home remedies did you try?
Not asked
No Response
6.2
Not Applicable
95
99
98
Did you seek treatment from any other clinic / dispensary / hospital before coming here?
Yes______
Not asked
No Response
1
95
99
No_________
Not Applicable
2
98
No_________
Not Applicable
2
98
Is this your first visit to this clinic?
7.
Yes
Not asked
No Response
1
95
99
Who advised you to seek treatment at this clinic?
8.
ANM_______
CHV_______
Other______
Can’t say
No Response
MPW_______
Neighbour
Not asked
Not Applicable
1
3
5
97
99
Did you know of the gynaecology clinic at this health post?
No
1
Not Applicable
Not asked
95
No Response
99
9.___
Yes
I
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2
4
95
98
2
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| Women Centred Health Project I Report of the End Evaluation
10.__
Yes
f
Did you think the doctor was listening to you while you were talking?
’
pl
No | 2
NA ’| 8
If yes, why?_____________
10.1
Reasons_____________ _ _______
Asked next question in according
to woman’s responses
Was recording all that the woamn said
on paper
Was nodding
Any other
Code
1
3
13
NR
9
Reasons_______________________
Did not talk to anyone else
while talking to woman
Was looking at the woman while
she talked
Asked questions - what is wrong etc ?
NA
NR
11.__
Yes
Could you answer all questions asked by the doctor?
i
No | 2
I
NA
11.a
If no, why?
8
NR
NA
8
NR
|
12.2
Yes
Did you know what PV examination is?
F
NA
8
NR
□
9
Did the doctor tell you that s/he needs to conduct PV or will do PV examination?
I
NA | 8
|
NR | 9
2
No
1
No | 2
4
14
98
99
8^
9
12.1
Yes
Pi
2
9
Not Applicable
No Response
12.___ Did you undergo PV examination ?
p
No TT
Yes
Code
9
Go to Q 12.2a if answer to Q 12.2 is ‘YES’.
12.3
If no, who informed you?
Mark the appropriate code with O
i
Response_______
Nurse
Ayabai
Any other (specify)
12.4
Code
1
3
5
Response
Doctor
Other patients
Not applicable
No response
Code
2
4
8
9
What did you feel while going for PV examination?
Mark the appropriate code with O
Response___________________
Nothing
Worry
Inhibited / awkward / uncomfortable
Any other
No response_________________
Code
1
3
5
7
99
Response
Alright
Anxiety
Scared
Not applicable
277
Code
2
4
6
98
j Women Centred Health Project I Report of the End Evaluation
12.5
Yes
After being informed about the PV examination, were you asked to lie down on the table?
No
8
NR
9
2
NA
12.5a
Who informed you?
r-
Mark the appropriate code with O
Response
Nurse
Ayabai
Any other (specify)
12.6
Yes
Code
2
4
8
9
Response
Doctor
Other patients
Not applicable
No response
Code
1
3
5
Were you asked to empty your bladder before PV?
NA
2
1
No
NR
8
zz
9
12.6.a Who informed you?
Mark the appropriate code with O
Response
Nurse
Ayabai
Any other (specify)
Code
2
4
8
9
Response
Doctor
Other patients
Not applicable
No response
Code
1
3
5
12.7
| Yes
Did you face any difficulties in using the toilet?
2
No
12.7a
If you had difficulties, what were they?
NA
NR
8
9
Not Applicable
No Response
8^
9
Ask 12.8.1 if the respondent has not mentioned the following in response to Q.4.c or if answer to Q
12.7a is‘NO’.
I
-•
12.8.1______________________________________
Did the toilet door have a latch?
Was the toilet clean?
Was there water in the toilet?
Were there any sanitary napkins discarded in the toilet?
Any other, please specify
Yes
No
NR
NA
i
13___ Were you told to remove undergarments and lie down for PV examination?
I
NA | 8
|
NR
2
No
| Yes
1
l
278
1
9
| Women Centred Health Project I Report of the End Evaluation
13.a
Who informed you?
Mark the appropriate code with O
13.2
Yes
Code
2
4
8
Response
Doctor
Other patients
Not applicable
Code
1
3
5
Response______
Nurse
Ayabai
Any other (specify)
Were you given enough time to undress?
2
No
1
NA
NR
8
9
3
Already knew about need to remove undergarments, did not wear, removed
Any other
13.3
Yes
Did you feel embarassed while undressing?
No
2
1
13.4
Yes
Was there enough privacy for undressing?
13.5
Yes
Were you informed about the result of the PV examination (either on the examination table or later on)?
I
NA | 8
|
NR | 9
2
No
13.6
Yes
Did the doctor explain the treatment to you?
14
Yes
Did you find the information provided at the clinic useful? Do you think it will help you in future?
I
NA | 8
|
NR | 9
H
2
No
15.__
Yes
Are prescribed medicines available at the clinic?
16.
What are the services available at the health post?
No
1
No
1
2
I '
NA
8
NR
9
NA
8
NR
9
NA
2
NR
8
9
n
I
1
Contraception
Immunisation
1
5
Not Asked
95
No
| 2
2
IB
For adolescent 6
girls
Not Applicable 98
|
NA
NR
8
ANC
Other
3
7
No response
99
17. What is your opinion about the services available at this centre?
279
I
9
Women’s health
4
| Women Centred Health Project I Report of the End Evaluation
18. In your opinion, is there a need for improvement in quality of these services? If yes, what improvements?
Response_____________________ _
Behaviour of the doctor
Crowd in the OPD
Seating arrangement for
accompanying persons
Work hours of the clinic / OPD timing
Patients should be looked after properly
Not Asked
Not applicable
Code
1
3
5
7
9
95
98
Response__________________
Behaviour of other staff members
Seating arrangements for patients
Medicines should be available
at hospital
Toilets should be available
Any other (specify)
Code
2
4
No response
99
6
8
10
19. Did you notice any difference between services provided at this clinic and private clinics, or other
municipal clinics? If yes, what? (note responses regarding time, fees, distance, investigations, treatment,
medicines)
Other Clinic
This clinic
Time
Fees
Distance
Investigations
Treatment
Medicines
20.__
Yes
Is your husband aware of your condition?
No
2
Ti
8
NR
9
21.__ Has the doctor asked your husband to come for treatment?
:
1
8
NA
No
2
Yes
NR
9
Did the doctor give you medicines for your husband?
NA
No
2
NR
9
21.1
Yes
22
Number of persons in the household?
Record actual number
NA
8
Not applicable 8
How many of these are earners?
22.1
Record actual number
|
Not applicable
|
280
1
8
No response
No response
9
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| Women Centred Health Project I Report of the End Evaluation
Informaion regarding educational status of the earners
Following information is to be recorded for the respondent, her husband and all earners from
the household. Information about the respondent and her husband is to be recorded irrespective
of their employment status. Mark appropriate response for each individual
24
23
Code Completed level of
Respondent Husband
education__________
Can not read , write
1
No formal education but can write
2
Upto Std. 4
3
Std. 5 -7
4
Std. 8-10
5
Std. 11 -12
6
Std 13-14
7
Diploma after 10th or 12th
8
Graduation
9
10 Post graduation
Any other (specify)
95 Interviewer did not ask / record
97 (Respondent ) Can not say
98 Not applicable
99 No response
25J
Other 1
26.2
25.2
26.1
Other 2 Child 1 Child 2
Source of income
Following information is to be recorded for the respondent, her husband and all earners from
the household. Information about the respondent and her husband is to be recorded irrespective
of their employment status. Mark appropriate response for each individual.
Code Occupation
27
Respondent
1
2
3
4
5
6
7
8
9
10
Housewife
Domestic help
Vendor (fru its/fish/eatables/plastic
goods etc.)
Sales person in a shop
Piece meal job (stitching for
readymade garments factory,
stitching buttons, trimming
threads, assembly of various
items etc.)
Work in a factory
Self employed (tailor/prepare and
sell food items/own rickshaw/
rickshaw driver etc.)
BMC employee (please record
designation)
Employee of State or National
government
Work at small industrial unit
Any other (specify)
I 281 1
28
Husband
29.1
Other 1
29.2
Other 2
| Women Centred Health Project I Report of the End Evaluation
95
Interviewer did not ask / record
97
98
99
(respondent) Can not say
Not applicable
No response
Monthly Income
Code Monthly income (Rs.)
1
2
3
4
5
95
97
98
99
30
Respondent
31
Husband
32.1
Other 1
32.2
Other 2
< =Rs. 2000
Rs. 2001 to 4000
Rs. 4001 to 6000
Rs. 6001 to 8000
> Rs. 8000
Interviewer did not ask / record
(Respondent ) Can not say
Not applicable
No response
We are grateful to you for answering all the questions and spending time for that. Thank you.
Other observations and Notes :
282
1
| Women Centred Health Project I Report of the End Evaluation
T-6.5
Baseline study for counselling centre at gynaecology out-patient
clinic of a secondary hospital
Women Centred Health Project
Public Health Department
Brihan mumbai Municipal Corporation
Baseline Exit Interview
Instructions for the interviewer:
Women in pain or those women who are in distress (not in position to speak or are unable to wait) should
not be asked for interview. Po not begin the interview without seeking consent. It is important to sign after
seeking consent.
The woman was informed of the following and her consent was sought for interview I am
. We are conducting a survey to understand possibilities of improving the services
provided through this OPP. We wish to know about your experiences regarding this OPP. We would like
to ask you a few questions. It will take around 15-20 minutes for asking these questions. Will you talk
to us? Will you give us the information? Information given by you will be kept confidential and will not be
misused.
(Allow the woman to think and say yes or no. If she refuses, request once again. If she refuses ask the
next patient / woman. If the woman agrees for the interview, say —)
If you wish to discontinue the interview please let me know. We will immediately stop the interview.
Signature of the interviewer
Name of the interviewer:
Time of beginning the interview:
Time at the end of the interview:
Unit:
Case paper no.:
Observation no.:
Pate:
New/Old
Age :
Name of the woman :
Marital status :
Sr. number
Married
Unmarried
1
Reason for coming to OPP
Reason for coming to this OPP
|
283
I
2
yrs.
Women Centred Health Project I Report of the End Evaluation
Code after the interview is over.
Mark the appropriate code with O
Reason for coming to OPD
Code
Missed periods / to confirm pregnancy 1
To get admitted for MTP
3
Want to have TL
5
For TL - to take appointment
7
Heavy bleeding
9
Pain in abdomen during meses
11
13
Itching / swelling / boils on vagina
15
Pain in abdomen / lower backache
17
Pain in abdomen during pregnancybefore term
19
White discharge during pregnancy
21
Vomitting during pregnancy
Adolescent girl - does not get periods 23
25
Swelling on legs
27
Repeated abortion
29
Giddiness and weakness
31
Cu-T hurts
33
Any Other
Reason for coming to OPD
Code
To take appointment for MTP
Came in labour for delivery
For Cu-T
For TL - to get admitted
Irregular periods
White discharge
Prolapse
Want children
Lower backache during pregnancy
2
4
6
8
10
12
14
16
18
Bleeding in pregnancy
Other compleaints during pregnancy
To show reports
Complications after the surgery
Fever
Heavy bleeding with lumps
Lump / swelling on uterus
No response
20
22
24
26
28
30
32
99
Reason for coming to this OPD
Code
Reason for coming to this OPD
Code
Stay closeby
Inexpensive treatment/Costs less
1
3
2
5
7
9
11
Always come here/regular user
Earlier satisfactory experience for self/others
All services available under one roof
Referred by private nursing home/hospital
Referred by municipal dispensary
Suggested by friend/relative
13
Any Other reason
14
Know staff member
Referred by private doctor
Referred by health post
Referred by municipal hospital
/ maternity home
Close to place of work
No response
A. Logistics
Seating facilities at the OPD
1.
Were you seated while you waited for the doctor to call you and while talking to the doctor?
I 284 I
4
6
8
10
12
| Women Centred Health Project I Report of the End Evaluation
Ask Q1.1 to 1.4 only if the woman has not answered these in her answer to Q. 1. Mark 4 for appropriate
code. If the woman has offered additional information regarding Q 1.1 to 1.4, record it in the place
provided below the table.
No
response
Not
application
No
Yes
1.1 Before examination, while waiting in the
corridor
1.2 While talking to the doctor prior to examination,
while telling about complaint
1.3 After history taking, while waiting for internal
examination
1.4 After investigation, while the doctor wrote on
the paper
Crowd
Did you have any problem while you waited in the queue?
Yes
ri
No | 2
|
' NA
1.
T
9
NR
Did you miss your turn?
2.
Yes
NA
NO
NA
If yes, why?
2.2.a
NR
2.2 While waiting outside ORD
NR
2.3.a
2.3 While waiting for history
taking
2.4 While waiting for PV
2.4.a
B Confidentiality
3. Did you think the doctor was listening to you while you were talking?
8
NA
| Yes
2
No
"1
If yes, why?_____________
Reasons_____________________
Asked next question in according to
woman’s responses
Was recording all that the woman
said on paper
Was nodding
Any other
T
3.1
3.2__
Code
1
3
13
□
9
NR
Reasons_______________________
Did not talk to anyone else while
talking to woman
Was looking at the woman while
she talked
Asked questions - what is wrong etc?
Code
NA
NR
98
99
2
4
14
Could you answer all questions asked by the doctor?
Yes
1
3.2.a
If no, why?
No
| 2
NA
I
8
NR
|
Not Applicable
No Response
285
1
9
8
9
; Women Centred Health Project I Report of the End Evaluation
3.3__
Yes
Did the doctor ask you any questions regarding sexual relationship?
1
No
2
NA
8
T
NR
9
Go to Q 3.4 if answer to Q 3.3 is ‘NO’. If the woman has not understood the question, ask Q 3.3.P
3.3.p. Did the doctor ask you whether you experience pain hurts during intercourse or whether you use
condoms or how often do you have intercourse etc.?
_________________________ ____
NR
9
NA
8
No
2
1
Yes
Go to Q 3.4 if answer to Q 3.3.P is ‘NO’
3.3.1
What did s/he ask?
Not Applicable
No Response
3.3.1 .a Could you answer these questions?
2
No
1
Yes
NA
8
NR
9
9
3.3.1.b If no, why?
8
9
Not Applicable
No Response
3.4__
Yes
Could you tell the doctor everything you wanted to tell?
NA
No
2
1
8
NR
9
Go to 3.5 if answer to Q 3.4 is ‘YES’
3.4.a
If no, why ?
Not Applicable
No Response
8^
9
3.5. Did the doctor ask you ‘do you have any other problem’ after you had finished telling everything you
wanted to tell?
1
Yes
4.0__
Yes
2
NA
8
NR
9
Could you talk freely to the doctor?
2
No
T
NA
8
NR
9
No
Go to Q 5 if answer to Q 4 is ‘YES’.
4.1
If no, why?
Not Applicable
No Response
5 Did you feel shy while talking to doctor?
No
2
Yes
1
NA
286
1
8
NR
8
9
9
| Women Centred Health Project I Report of the End Evaluation
Go to Q 6 if answer to Q 5 is ‘NO’.
5.1
If yes, why?___________
8^
9
Not Applicable
No Response
6.
Yes
Did anything or anyone interrupt your communication with doctor?
NA | 8
1
No~ 2
”
I
NR
9
Go to Q 6.2 if answer to Q 6 is ‘NO’.
6.1
If yes, what caused interruption?
Hark the appropriate code with O
Reason for interruption_______
Doctor was talking to other doctor
Doctor was talking to other person
(medical representatives / friends etc
Doctor left the table / OPD
Phone was ringing
Not applicable.
Code
1
Reason for interruption
Doctor was talking to other staff
3
5
Doctor was talking to other patients
There was disturbance because of
other patients
Any other
No response
7
98
Code
2
4
6
8
99
6.2__
Yes
Were other patients standing around the table while you were talking to the doctor?
9
NR
8
'
2
I
NA
No
1
7.
Did you want to ask private questions (e.g. about intercourse etc.) to the doctor?
Yes
•
’
’
1
No
2
Yes
No
1
NA
NR
8
9
NA
NR
8.
9
Go to Q 8 if answer to Q 7 is ‘NO’.
7.1
If yes, could you ask these questions?
2
Go to Q 7.3 if answer to Q 7.1 is ‘YES’.
7.2
If the woman has wanted to ask private questions but has not been able to ask questions, ask
why?____________________
. _______
8
Not Applicable
9
No Response
7.3
Yes
If the woman has asked private questions to the doctor, did the doctor answer these questions?
9
NR
8
| 1
|
No | 2
|
NA
287
1
( Women Centred Health Project I Re por t o f t h e En d E v a I u a t i o n
Internal examination
C.
Preparation
8.
Did the doctor tell you that s/he needs to conduct PV or will do PV examination?
9
NR
NA
2
No
Yes
T
Go to page 13, Q 19 if answer to Q 8 is ‘NO’. If an unmarried woman has undergone PR, record this
clearly and ask all questions for PV examination.
8.1__
Yes
Did you know what PV examination is?
•
th
n
no
i 2
r
NA
8
T
NR
9
Go to Q 8.2 if answer to Q 8.1 is ‘YES’.
If no, who informed you?
8.1.a
flark the appropriate code with O
Response
Nurse
Ayabai
Any other (specify)
Code
1
3
5
Response
Doctor
Other patients
Not applicable
No response
Code
2
4
8
9
Response
Alright
Anxiety
Scared
Not applicable
Code
2
4
6
98
What did you feel while going for PV examination?
8.2
Mark the appropriate code with O
Code
1
3
5
7
Response
_______________
Nothing
Worry
Inhibited/awkward/uncomfortable
Any other
No response 99_____________ _
8.3
After being informed about the PV examination, were you asked to lie down on the table?
2
|
NA | 8~
NR [ 9
Yes 1______ No
Go to Q 8.4 if answer to Q 8.3 was ‘NO’.
8.3.a
Who informed you?
Mark the appropriate code with O
Response____
Nurse
Ayabai
Any other (specify)
No response
8.4
Yes
Were you asked to empty your bladder before PV?
1
No
| 2
Code
2
4
8
Response
Doctor
Other patients
Not applicable
Code
1
3
5
9
___
NA
I
I
288
1
8
I
NR
9
| Women Centred Health Project I Report of the End Evaluation
Go to Q 8.5 if answer to Q 8.4 was ‘NO’.
8.4.a
■
Who informed you?
Mark the appropriate code with O
Response____________________
Nurse
Ayabai
Any other (specify)
Code
1
3
5
Response
Doctor
Other patients
Not applicable
No response
Code
2
4
8
9
8.4.b.1 Did you have any difficulty in locating the toilet?
Yes
1
No
2
NA
8
NR
9
8.4.b.2 Did you face any difficulties in using the toilet?
1
No ’ 2
Yes
8
NR
9
8.4.C
NA
If you had difficulties, what were they?
?
Not Applicable
No Response
S
9
Ask Q 8.4.p if the woman has not mentioned the following in response to Q.4.c or if answer to Q 8.4.b.2
is ‘NO’.
8.4.P__________________________________
Did the toilet door have a latch?
Was the toilet clean?
Was there water in the toilet?
Were there any sanitary napkins discarded in the
toilet?
Any other, please specify
8.5
Yes
Yes
No
NA
Were you told to remove undergarments and lie down for PV examination?
1
No
2
NA
8
i
NR
NR
9
Go to Q 10 if answer to Q 8.5 was ‘NO’.
8.5.a
Who informed you?
Mark the appropriate code with O
'>
Response
Nurse
Ayabai
Any other (specify)
Code
1
3
5
I
Response
Doctor
Other patients
Not applicable
289
1
Code
2
4
8
| Women Centred Health Project I Report of the End Evaluation
8.6
Were you given enough time to undress?_____________________
No | 2
|
NA | 8
n
Yes
Already knew about need to remove undergarments, did not wear, removed
frny other
8.7
Yes
Did you feel embarassed while undressing?
2
Ti
no
NA
H
8.8
Was there enough privacy for undressing?
| 1
|
No | 2
|
NA
8
Yes
NR
3
T
NR
9
NR
9
Preparing the woman for lying down on the examination table
Were you informed about how to lie down on the examination table and about position of legs?
10.1
NA | 8
Yes
No
2
I 1
-q
| 9
Go to Q 10.1 .c if answer to Q 10.1 is ‘NO’.
10.1 .a Who informed you about the position to be taken for PV examination?
Hark the appropriate code with O
Code
2
4
Response
Doctor
Other patients
Not applicable
Code
1
3
5
Response
Nurse
Ayabai
Any other (specify)
8
Ask Q 10.1.b first. If the woman does not understand Q lO.I.b, ask 10.1.P.
Mark the appropriate code with O for Q 10.1.b. For rest of the instructions ask Q 10.1.p and
mark appropriate code
10.1. p (probe)
10.1 .b. What instructions
were you given regarding
taking position on the
examination table for PV
examination?
Mark the appropriate
code with O___________
J
Mark appropriate code with
Instruction______________ Code
Use the small stool to climb
1
on the examination table
Lie down and shift towards
2
the foot-end of the table
Fold your legs and place here 3
Take your clothsup
Move legs upwards
Separate legs
Any other (specify)
______________ _
4
5
6
7
Yes
Were you told to use the small stool
to climb on the examination table?
Were you told to lie down and shift
towards the foot-end of the table?
Were you told to fold your legs
and place here?
Were you told to take your cloths up ?
Were you told to move legs upwards?
Were you told to separate your legs?
Were you given any other instructions?
(specify)
290
1
No
NA
NR
| Women Centred Health Project I Report of the End Evaluation
Go to Q 10.2 if response for all questions in 10.1 .p is ‘NO*.
10.1 .c Who gave you these instructions?
Record the response if the woman can answer this question easily. Else, do not probe.
For each of the instructions, mark appropriate code with
Not
Other
Any
No
Doctor
Ayabai
Response
Nurse
response
patients other appicafon
Use the small stool to climb
on the examination table
Lie down and shift towards
the foot-end of the table
Fold your legs and place here
Take your cloths up
Any other (specify)
Were you informed about the procedure of PV examination? (Were you informed about what the
10.2
doctor will do during PV examination?)______ _____________ ___________ _______ ___________
NR
9
NA
8
2
No
Yes
1
Go to Q 10.4 if answer to Q 10.2 is ‘NO’.
10.2.a Who informed you about the procedure for PV examination?
Mark the appropriate code with O
Response____________________
Nurse
Ayabai
Any other (specify)
Code
Code
~2
4
8
Response
Doctor
Other patients
Not applicable
“l
3
5
Instructions regarding PV examination
11.1
Yes
Was there privacy during PV examination?
1
No
2
I
NA
NR
8
9
Did you think that women sitting on the bench could see you while you underwent the PV
11.2
examination?______________________________________________________
I
NA | 8
NR
9
No | 2
Yes
.1
Were your legs covered during PV examination? (If the woman was given the draw sheet but has
11.3
not used it, clearly record this).
Yes
1
No
I
NA
8
Were you rushed to climb on the examination table?
| 2 ’
NA
I 1
I—No
—
8
2
T
NR
9
NR
9
During internal examination
12.1
Yes
T
291
I
I Women Centred Health Project I Report of the End Evaluation
__________ —liiMau^a—i
___________________
y
Waitng time
12.2
IHow long was the gap between your lying down on the table and doctor coming there to examine
you?minutes
Response____________ _
Code
Response
Code
Immediately (<= 5 minutes)
10- 15 minutes
30 - 60 minutes
Could not reply
No response
1
3
5
7
99
>5 and <10 minutes
16 -30 minutes
More than 1 hour
Not applicable
2
4
6
98
12.3
Yes
Did it hurt you during the PV examination?
| 1
|
No | 2
I
12.4
Yes
Did the doctor do anything to lessen your fear during PV examination?
|
No | 2
|
NA | 8
|
NA
n
Ask Q 12.4.p if answer to Q 12.4 is ‘NO’.
12.4.p Did s/he say don’t be scared, it will not hurt etc?
Yes
8
~
1
No I 2
I
I
NA
8
NR
9
NR
9
NR
9
Ask 12.4.a if answer to Q 12.4 or Q12.4.p is ‘YES’.
What did the doctor say / do to lessen your fear during PV examination? ---------12.4.a - -------------------- .
--------- --------------------Not Applicable
------- ---------------------- “
No Response
12.5
Yes
Did the doctor do anything to lessen your shyness / embarrassment?
Pi
No
2
|
NA | 8
T
8
9
9
NR
Go to Q 12.6 if answer to 12.5 is ‘NO’.
12.5.a If yes, what ?
12.6
Did the doctor talk to you or ask you any questions such as about your complaint during internal
examination?
Yes
12.7
12.8
Yes
No
1
NR
NA
2
|
9
h
Were you informed about the result of the PV examination (either on the examination table or
later on)?
Yes
8i
9
Not Applicable
No Response
.
Fs
NR
P9
Were you rushed to climb down from the examination table?
| 1
|
No | 2
I
NA | 8
NR
9
I 1
I
No
NA
2
|
292
1
□
Women Centred Health Project I Report of the End Evaluation
Were you told to move upwards on the examination table and then to climb down ?
12.9
9
NR
NA ' 8
2
No
Yes
I 1
I
'
Ask Q 12.10 if answer to Q 12.9 is ‘NO’.
12.9.a Who informed you?
Mark the appropriate code with O
Response
______________
Nurse
Ayabai
Any other (specify)
12.10
Code
2
Response
Doctor
Other patients
Not applicable
Code
1
3
5
Were you examined by a male or a female doctor?
Male
|
2
1
Female
4
8
8
NR
Go to Q 12.11 if examining doctor was a female
12.10.a If woman was examined by a male doctor ask, did you feel embarrassed?
NR
NA | 8
Yes
0
No | 2
|~
T
Mark appropriate code with
Was the nurse / ayabai present
during your PV examination?
NR
| Yest No NA
F- -
If rude, explain.
Was she rude or polite?
Polite
12.11
Rude NA
12.11.a
9
NR
______ NA
NR
12.11.b
Nurse
12.12.b
12.12.a
12.12
Ayabai
For Q 12.13 -12.14 mark appropriate code with
Ask Q 12.13.a and Q 12.14.a only if answer to Q 12.13 and Q 12.14 is ‘YES’.
If rude, explain.
Did the presence of a nurse/ayabai
during your PV examination help
lessen your fear or embarrassment?
Yes | No | NA | NR~
NR
NA
12.13.a
12.13
Nurse____________ ___________
12.14
______ r——
12.13.a
Ayabai]
Communication
13.__ Has anybody accompanied you to the hospital today?
'
No | 2
I
NA | 8
Yes
13.1
Who has accompanied you?
293
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Communication with accompanying person
For Q 13.2mark appropriate code with
Ask 13.2.a if answer to Q 13.2 is ‘RUDE’.
13.2. Was the doctor, nurse,
ayabai other staff polite with you?
Yes
No
NA
Doctor
Nurse
Ayabai
Other staff
13.2.a.
If rude, explain.
NR
NA
NR
NA
NR
14. Behaviour with the woman
For Q 14, mark appropriate code with
Ask 14.1 if answer to Q 14 is ‘RUDE’.
14. Was the doctor, nurse,
ayabai other staff polite with you?
No
NA
Yes
Doctor
Nurse
Ayabai
Other staff
13.2.a.
If rude, explain.
NR
15-16. Shouting at / insulting the woman
For Q 15.1 to 15.4 and 16.1 to 16.4 mark appropriate code with
Ask Q 15.1.a to Q 15.4.a and Q 16.1.a to Q 16.4.a if answer to Q 15.1 to Q15.4 and Q16.1toQ16.4
is ‘YES’.________________________
Did the doctor, nurse, ayabai other staff shout at
or insult you?
NR
NA
No
Yes
Doctor Shouted 15.1
Insulted 16.1
Shouted 15.2
Nurse
Insulted 16.2
Ayabai Shouted 15.3
Insulted 16.3
Shouted 15.4
Other
If yes, explain.
NR
NA
staff
Insulted 16.4
Did anything in the ORD bother you? (Did you witness any unpleasant event?)
17.
Record clearly if the woman did not understand the question.
NR
I 1
I
No | 2
|
NA
Yes
n
17.1
T
9
If yes please specify.
Not Applicable
No Response
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18. Did you encounter / witness any event in the ORD concerning yourself or other patients that you did
not like or found objectionable?
If the woman does not understand Q18 ask Did you encounter or witness any event in the ORD concerning yourself or other patients that you wished
had not happened?
Yes
1
No
2
NA
8
NR
9
18.1
If you experienced an objectionable event, please specify.
Not Applicable
No Response
8.
9
E.
Information giving
Information regarding diagnosis
19.1
Did the doctor tell you what your condition is or why are you suffering from this problem?
Yes
1
No
2
NA
8
NR
9
19.1.a
If you were told about your problem, please specify.
Not Applicable
No Response
8.
9
Go to Q 20 if the woman has not come to the ORD for contraception or/and MTP. Ask questions regarding
Cu-T and TL in case the woman has come to ORD for such services.
For a woman seeking MTP services
19.2
Did the doctor tell you anything about abortion?
Yes
No | 2
I
1
NA
8
NR
9
Go to Q 19.3 if answer to Q 19.2 is ‘NO’.
19.2.a
If yes, what did the doctor tell you about abortion?
Not Applicable
No Response
8
9
For woman seeking MTP and/or contraception services
19.3
Yes
Did the doctor inform you regarding family planning operation?
No
2
NA
8
1
NR
9
Go to Q 19.4 if answer to Q 19.3 is ‘NO’.
j
■
19.3.a If yes, what did the doctor tell you about family planning operation?
___________________________________________________________ Not Applicable
No Response
19.4
Yes
Did the doctor tell you about Cu-T?
1
No
2
NA
295
1
8
NR
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| Women Centred Health Project I Report of the End Evaluation
Go to Q 20 if answer to Q 19.4 is ‘NO’
19.4.a If yes, what did the doctor tell you about Cu-T?
89
Not Applicable
No Response
Understanding the information given by the doctor
20.__ Did you understand the information the doctor gave you?
I
NA | 8
2
No| Yes
n
NR
9
If the woman does not understnd Q 20, ask Q 2O.p. Go to Q 21 if answer to Q20 is ‘YES’.
Did you understand the information regarding your problem / MTP / contraception that the doctor
2O.p
gave you?
i
NR | 9
NR
NA
2
No
| Yes
n
Q
Go to Q 20.1 if answer to Q 20 or Q 20.p is ‘NO’
Go to Q 21 if answer to Q 20 is ‘YES’.
20.1
21.__
Yes
21.1
If the woman has not understood the information, ask, why did you not understand it?
------Not Applicable
No Response
1
9
Did the doctor confirm that you have understood the information that s/he gave?
NR |9
NA
| 1
|
No |~2
If yes, how did he confirm that you have uynderstood the information that s/he gave?
Mark the appropriate code with O
Response__________ _____
Asked whether understood
Repeatee the information to the
accompanying person
Any other (specify)
Not applicable
Code
Response______________
2
Asked to repeat
4
Repeated the same information
Code
1
3
5
98
99
No response
Usefulness of the information given in the ORD
Before coming to this OPD, had anybody else given you the information regarding your problem
22.1
I
or contraception that the doctor in this OPD gave you?
9
NR
8
NA
2
No
| Yes ~
H
■ I
T
22.2
| Yes
Did you find it useful? Do you think it will help you in future?
NA 18;
I 1
1 No ’
'
LZ
Regarding treatment
23.__ Did the doctor prescribe any medicines for you?
NA
2
No
| Yes
I 1
1
296
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T
NR
9
NR
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23.1
What did s/he prescribe? For what reason?
Response
Code
Response
Code
Tablets
1
Capsules
2
Syrup
3
Ointment
Pessaries
5
Can not say
7
Any other
Not applicable
4
6
8
No response
9
23.2
| Yes
Did you underestand instructions regarding medicines given by the doctor?
| 1
|
No | 2
I
NA | 8
I
NR
n
_9
Go to Q 23.2.b if. the woman did not understand the instructions
23.2.a
If the woman has understood the instructions regarding medicines, ask her to repeat the following
details.
Record as N OT AP PL I CABLE when the woman has not understood the instructions.
For how many days?
How to take it?
Where to get it from?
Medicine_______
Tablet 1_________
Tablet 2_________
Tablet 3_________
Capsule 1_______
Capsule 2______
Capsule 3______
Ointment
Syrup
Pessaries______
Any other (specify)
J
Other notes regarding treatment:
If you did. not understand the instructions given by the doctor, did you ask the doctor to repeat the
23.2.b I .
instructions?
Yes
No
1
NA
2
D.
NR
El
Go to Q 23.2.d if answer to Q 23.b is ‘YES’.
23.2.C If the woman has not asked the doctor to repeat, ask, why?
8^
9
Not Applicable
No Response
24.__
Yes
24.1
Did the doctor confirm that you understood the instructions?
| 1
|
No
| 2
NA
I
| 8
I
NR
If yes, how did he confirm that you have uynderstood the information that s/he gave?
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Mark the appropriate code with O
Response___________________
Asked whether understood
Repeat the information to the
accompanying person
Any other (specify)
Not applicable
Code
Response______________
2
Asked to repeat
4
Repeated the same information
Code
1I
3
5
98
99
No response
Regarding investigations
25.1
| Yes
Were you advised any investigations?
No
2
f
1
NA
8
NR
9
25.2 Were you informed / told about what investigations, purpose of doing these, where would you have
to get these done from, how much will it cost, when will you have to come back with reports etc?
Ask the patient to repeat the information
Where
Purpose
Investigation
How much
will it cost
Regarding surgery
Did the doctor tell you anything regarding operation?
26.
NA
2
No
| Yes •
I 1
I
26.1
8
When to come
back with reports
NR
J
9
What did the doctor tell you regarding surgery? Please tell me.
13
9
Not Applicable
No Response
Go to Q 27 if answer to Q 26 is ‘NO’.
26.2
Did the doctor tell you following —
Ask the patient about the following ._____ r
When
Purpose
Operation
26.3
| Yes
Where
How
Preparations for surgery
Could you ask all queries / doubts regarding the surgery?
| 1
|
No
| 2
NA T~8
|
NR
9
Go to Q 26.4 if answer to Q 26.3 is ‘YES’.
26.3.a
If no, why?
Not Applicable
No Response
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26.4
Yes
If the patient has asked all doubts regarding surgery, did the doctor answer all of your questions?
NR
9
NA
8
n
No I 2 |
~
’
Go to Q 27 if answer to Q 26.4 is ‘NO’.
26.5.
Yes
If the doctor answered all questions, did you understand the information that the doctor gave you?
NR
9
1
No | 2 ~~T
NA
Go to Q 27 if answer to Q 26.5 is ‘NO’.
26.5.a If the doctor has answered the questions, please tell me one question you asked and the answer
doctor gave for that question?
___________________
8^
Not Applicable
9
No Response
26.6
Yes
Did the doctor confirm that you have understood all instructions regarding the surgery?
9
1
-No | 2 ~T
NR
8
NA
Go to Q 27 if answer to Q 26.6 is ‘NO’.
26.6.a
If yes, how did he confirm that you have uynderstood the information that s/he gave?
Mark the appropriate code with O
Response__________________ __
Asked whether understood
Repeatee the information to the
accompanying person
Any other (specify)
Code
Response
Asked to repeat
Repeated the same information
Code
1
3
5
“2
4
98
99
Not applicable
No response
Regarding services provided through the OPD
27.
Yes
Did the doctor ask you if you had any doubts?
2
No
1
NA
8
NR
9
27.1
Yes
Did you ask any questions / doubts to the doctor?
NA
n
8
NR
9
27.1 .a
Yes
If yes, did the doctor answer the questions?
1
No
2
|
8
NR
9
Advice regarding sexual relations
28.__ Did the doctor advice you regarding sexual relationship?
1
No
2
|
8
NA
Yes
NR
9
ri
n
°
2
i
NA
Ask Q 28.p if the woman did not understnad q 28.
Go to Q 29 if answer to Q 28 is ‘NO’.
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| Women Centred Health Project I Report of the End Evaluation
28.p
Did the doctor tell you anything regarding having intercourse in your present condition, regarding
contraception?
Please record if this question was not asked._____________________________________ _____ ,
9
8
NR
NA
Yes
1
No
2
T
Go to Q 29 if answer to Q 28 or Q 28.p is ‘NO’.
28.1
What did the doctor tell you regarding sexual relations ?
8
9
Not Applicable
No Response
Need for more information
29.__ Do you need more information?
n
no r~2
Yes
NA
NR
8
9
Ask Q 29.p if the woman did not understand Q 29.
Do you wish to have more information regarding your current problem, investigations, medicines
29.p
prescribed for you, surgery that is adviced etc?
9
NR
8
NA
Yes
Fi
No r~2
[
on which subject would you like to have more information?
29.1
If the woman needs more infcformation,
—
Mark the appropriate code with C
Code
Response_________________
Response______ ______________ Code
_______
o
About the present problem /condition “i
3
About medicines
5
Regarding contraception
7
Any other (specify)
98
Not applicable
About investigations
About operations
About services available at the hospital
”2
4
6
99
No response
Follow-up
30.
Did the doctor as k you to come for follow-up?
Yes
Pi
No
2
NA
|
NR
8
□
9
Go to Q 31 if answer to Q 30 is ‘NO’.
30.1
30.2
If yes, when has the doctor asked you to come back?
Not Applicable
No Response
9
Not Applicable
No Response
8
9
If no, why were you not asked to come back?
Go to Q32 if this is the woman’s first visit to the gynecology ORD.
For woman who has come for a follow-up visit
Did the doctor ask you about medicines prescribed in your last visit?
31.1
| 1
|
No | 2
|
NA
8
| Yes
300
1
NR
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| Women Centred Health Project I Report of the End Evaluation
31.2
Yes
Did the doctor see the reports of investigations advices during your last visit?
1
|
No | 2
|
NA
8
NR
Woman’s opinion about services provided
32.
Are you satisfied with services provided through this OPD?
Yes
| 1
|
No | 2
I
NA | 8
•t
9
NR
ZZ)
9
32.1
Yes
Do you have any suggestions for improving the services provided through this hospital?
| 1
|
No
| 2
|~
”
~
NA * ' ~ 8
NR
9
32.1 .a
If yes, what are the suggestions?
Response_________________
Behaviour of the doctor
Behaviour of ayabai
OPD timings
Crowd in the OPD
Seating arrangement for
accompanying persons
Reduction in fees
Centre for giving general information
Any other (specify)
Not applicable
Code
1
3
5
7
Code
2
4
6
8
9
11
13
Response_____________________
Behaviour of nurse
Behaviour of other staff members
Timings for investigations
Seating arrangements for patients
Medicines should be available
at hospital
Toilets should be on the same floor
Patients should be looked after properly
98
No response
99
10
12
14
Social information
33.1
Number of persons in the household?
Record actual number
Not applicable
8
No response
9
33.2
How many of these are earners?
Record actual number
Not applicable 8
No response
9
Information regarding educational status of the earners
Following information is to be recorded for the respondent, her husband and all earners from
the household. Information about the respondent and her husband is to be recorded irrespective
of their employment status. Mark appropriate response for each individual.
Code Completed level of education
1
2
3
4
5
6
7
8
9
10
34.2
Husband
34.1
Respondent
Can not read , write
No formal education but can write
Upto Std. 4
Std. 5-7
Std. 8-10
Std. 11 -12
Std 13-14
Diploma after 10th or 12th
Graduation
Post graduation
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34.3
Other 1
34.4
Other 2
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95
97
98
99
Any other (specify)
Interviewer did not ask / record
(respondent). Can not say
Not applicable
No response
Source of income
Following information is to be recorded for the respondent, her husband and all earners from the household.
Information about the respondent and her husband is to be recorded irrespective of their employment
status. Mark appropriate response for each individual.
Code Occupation
1
2
3
4
5
6
7
8
9
10
95
97
98
99
35.1
Respondent
35.2
Husband
35.3
Other 1
35.4
Other 2
Housewife
Domestic help
Vendor (fruits / fish / eatables/
plastic goods etc.)
Sales person in a shop
Piece meal job (stitching for
readymade garments factory,
stitching buttons, trimming threads,
assembly of various items etc.)
Work in a factory
Self employed (tailor/prepare and sell
food items/own rickshaw/rickshaw
driver etc.)
BMC employee (please record
designation)
Employee of State or National
government
Work at small industrial unit
Any other (specify)
Interviewer did not ask / record
(respondent) Can not say
Not applicable
No response
We are grateful to you for answering all the questions and spending time for that. Thank you.
Other observations and Notes :
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Annexure 7
T-7.1
Communication tool- interview guide
Objectives: To know the usefulness and importance of monitoring communication style and
attitude towards improving communication.
To be applied to
2 Security guards at Kherwadi and MMH
2 R.A.s (one at each facility)
2 Attendants
2 Lab. Technicians
2 Pharmacists
2ANMs
2MPWs
2FTMOS
1 MO i/c Disp. (Kherwadi)
2 MO i/c Mat. Home
1 MO (pediatric) Kherwadi PPG
1 a)What are your views on provider -patient communication ?
1b) Does the quality of the provider -patient communication contributes to the patients satisfaction
regarding the services? How ?
2a) What is your opinion on the present condition of the provider -patient communication in your
facility ?
2b)Do you feel need to improve provider -patient communication style in your facility? Why?
3) What can we do to make our communication with the patient more effective?
4) What are the barriers in doing this ? How can we overcome them?
5) On what basis did you answer question (2a). How do we know that our communication style is
efffective or not ?
OR
6) What are the standards on the basis of which we can say that the patient-provider communication is
effective or not ?
7) What can we do for regular monitoring of the same?
Questions regarding Communication Tool Used
8) What role did you play in this exercise ?
Observer
Observes
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FOR OBSERVER
9)What were your feelings or experience in performing the role of observer ?
10)What problems did you face in performing the above role ? What are your suggestions to overcome
these problems?
Suggestion
Problem
1.
2.
3.
4.
FOR OBSERVES
11) How did you feel being observed ?
12)What problems did you face as an observee ? What are your suggestions to overcome these
problems?
Suggestion
Problem
1.
2.
3.
4.
13) What is your opinion on the use of the communication tool in your facility usuful?
13a) Was it usuful ?
yes/no
If yes , How ?
If no, why?
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T-7.2
Interview guide for the core group members of the communication
1) Dr. Mathur
MO i/c
3) Ms. Varsha Joshi ODO
Kherwadi Mat. Home
H/E Ward____________
2) Mrs. Tambe PHN
4) Ms Bharati Ghule
Kherwadi Health Post
ANM
WCHP
You were part of the core group for planning and implementing the communication monitoring exercise
at Kherwadi.
a)
What was your role and contribution in planning and implmenting this exercise?
b)
What were you responsible for ? What did you participate in?
Attending QA workshops
Developing the tool
Orientation of the staff
Training of observers
Pretesting of the tool
Feedback from the observers and the observees
Group discussion with the patients
Data collection (Observer)
Data analysis
Sharing the findings
Any other
c)
What problems did you face during carrying out this activity ?
d)
What did you do to overcome them?
e)
Why was this exercise discontinued ?
f)
What is your opinion on the extention / continuation of this exercise ?
g)
Did participation in this exercise result in any changes in yourself ? (In your perspective ,
abilities, knowledge and communication skills.)
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T-7.3A
Questionnaire for key trainers
Objective:
1 )To check whether their perspective has changed about participatory training process and philosophy?
Whether they have understood and internalised the importance of participatory training.
2)To asses their training skills.
MIDTERM EVALUATION
Queationnaire for key trainers
1. In your opinion what are the three most important aspects or goals of participatory training?
a.
___________________________ __ ______________________________
b. ___________________________ :___________________________ __________
c.
2. Has being part of WCHP key trainers group made any difference,
a. In your work life ? If yes, what or how ? If no, why ?
b. In your personal life ? If yes, what or how ? If no, why ?
3. What have you learnt being a trainer ?
a. What should a trainer Know ?
b. What skills should a trainer have ?
»
c. What attitudes should trainer have ?
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4. Do you think you can make use of the above learnings in your daily work ? If yes, how ?
(Explain, giving a specific situation). If no, why ?
5. List down five participatory methods of training.
a.
b. _______________________
c._
d.
e.
6. In the following table, write why we do the following in the training that you have attended or
conducted :
Why ? Or importance or significance of this?
a) Circular sitting arrangement
b) Introducing a partner rather than introducing themselves
c) Small group work and sharing in the larger group
d) Combination of different categories of trainees
e) Inclusion of session on human behaviour
f) Inclusion of session on listening skills
g) Preparing action plans in group
h) Feedback to the training team after the training
i) Inclusion of icebreaker songs, games
7. Is there a need to follow-up with trainees, after the training ? For what purpose ?
THANK YOU
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T-7.3B
Interview guide for indepth interview with Key Trainers
In addition to the (11) trainers, ask the first question to Mrs. Sonawane, Dr. Sujata Busa, Ms.
Seema Waghpanje, Ms. Savita Tambe because they have worked as trainer in CSSM and
School AIDS programme.
1. What do you feel about being a trainer in WCHP initiative ?
2. What are your experiences as a key trainer in the WCHP initiative ?
3. Have you worked as a trainer before ? If yes, was this experience different than in other
training ? How ?
4. Tell us about your one positive and.one negative experience in conducting ANMs/MPWs and
CHVs training ?
ANM/MPW training
Positive experience
Negative experience
CHV training
Positive experience
Negative experience
mducted both ANM/ MPW and CHV trainings, were there differences in two trainings?
5. If you have coi
What ?
OBSERVATION DURING TRAINING
To be applied to Trainers for inservice training and CHVs training as well as Non Trainers
Trainers:
Ms.NaliniShinde, Ms. Seema Waghpanje, Ms. Kalpana Chodankar, Ms. Savita Tambe, Ms. Sonawane,
Ms. Korgaonkar
Non Trainers:
3 PHNs from other wards
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OBSERVATION CHECKLIST
Observation sheets would be filled by the external observers during in-service and CHV training of
WCHP key trainers and the other key trainers.
1)
Did the trainer make use of any participatory method? If yes,which methods?
2)
How was the participation from the trainees? (3 out of 7 things listed defining what is participation )
No participation
Very few
Many
Almost all
3)
How did they handle group dynamics ? ( Defining - list of group dynamics )
Very well
Satisfactorily
Could not handle satisfactorily
Did not even attempt to handle
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Perspective development questionnaire for Midterm Evaluation
Objective:
To check whether there is greater sensitivity to gender, women’s health, participation and communication,
team work and developing better work culture
Questionnaire to be applied to :
16 CH Vs (8 from each ward)
5 ANMs and 5 MPWs (10 from each ward )
10 key trainers (5 from each ward )
6 FTMOs(3 from each ward)
6 Disp. M.O.s(3 from each ward)
GENDER
1) What is gender ?
2) Is it important to consider gender in implementation of health programmes ?
yes/no
Why? Give one example.
3) Give one example how gender based roles and stereotypes affect men and women’s family planning
choices and decisions ?
4) What would you as a health care provider/ policy maker do to bring about gender just family
planning policies and programme ?
5) Women are less able than men to make decisions.
Agree/disagree
why?
6) Men have more difficulties than women in protecting themselves from STDs
Agree/disagree
Why?
7) A disease affects man and women in the same way biologically and socialy.
Agree/disagree
Explain with one example.
8) Can you share one personal experience based on gender stereotyping at your workplace or in
personal life and also describe what are you doing to deal with it.
;
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WOMEN’S HEALTH
Read the following cases and answer the questions below :
(a) Scene in the OPD at the health post
Health worker: There is no problem in this (inserting Cu T). So many women have got it, I have also got
it inserted. You people don’t listen to us. If you have any problem, you can always see the doctor here
Do you understand? The population is increasing like cats and dogs and lots of people don t get enough
to eat. Now go and come tomorrow at 10 to get the Cu T.
Woman : But I have not informed at home, my husband won’t allow me to get it.
Health Worker: Your are absurd. You only want to give excuses. Come on... you come here tomorrow
I am doing it for your good. Don’t you understand ?
The woman never came to get the Cu T. When CHV went to her house to find out, the woman told her that
her husband beat her up when she mentioned the Cu T. CHV could see a bruise on woman’s head.
Q1 : What should the health worker find out before giving advise on FP methods to the woman in the
above case.
Q2 :What are the different factors that affect women’s decision making in the household other than the
factors mentoined in the above case?
(b) Rajani developed fever the next day of her TL operation. She went to the HP. There she was told to
go to the facility where her TL was done. Her husband had left for work and she had requested her
neighbour to look after her 2 kids. How could she go to that hospital leaving her children for so long
She
returned home that day. The next day also she had high fever but she could not leave her house as there
was no one to look after the kids. Later in the evening she developed abdomenal pain. Next morning she
woke up with severe pain and fever yet she had to do the cooking, cleaning and washing. At 2.30 in the
afternoon, after completing the chores, Rajani requested her neighbour to take care of her kids and set
out for the hospital where her TL was done.
The sister saw her case paper, checked her and told her that doctor had left and that she should have
come early. “What were you doing for 2 days. You have developed complications. You women are not
concerned about your health and then you want to put the blame on the hospital. Now get admitted.
Doctor will come in the morning for checking. Rajani was lost in thoughts. “ What will happen to my little
daughter? who will give my son his snacks after returning from school? What will my husband say? He
doesn’t know anything”.... Rajani was nervously trying to take decisions and the sister was shouting at
her, “What are you thinking? You are so ill so what’s the problem in getting admission? I am telling you
to get admitted Aren’t you ill? Are you really ill? Or are you feigning?
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Q 1 : What are the barriers which prevented Rajani from seeking early treatment ?
Q2 : What could be the other (than mentioned in the above case) factors that prevent women from
seeking early treatment.
(c) For a very long time, Asha has been suffering from itching in the genital area and rash. Municipal
General hospital happens to be close to her home. But she does not go there for treatment and has
been applying the creme which was prescribed to her children for scabies. Her problem is getting worse
What could be the reasons for Asha to avoid to go to the municipal hospital for the treatment for her
problem ?
(d) A health education session was being conducted in a pavement settlement. The topic was menstruation
and the PHN was telling the women that it was necessary to wash twice during the menses and to use
sterilised pads. One woman rose up and said, “Sister, we have no water connection in our settlement.
We barely manage to get some drinking water. How is it possible to wash twice and the ready made are
expensive?”
Q1: What are the barriers for women staying in the slum, to maintain personal hygiene during menstruation
in the above case ?
Q2 : Also mention other(than mentioned in the above case) barriers that prevent women (staying in the
slum areas )from maintaining personal hygiene.
2) community wmen are not clean because they do not like to remain clean and they have got used to
remaining dirty.
Agree/disagree
3) What are the suggestions to improve women’s reproductive and sexual health through your facility ?
4) Negligent attitude is the only cause for women to suffer from health problems
Agree/disagree
5) All the women’s health problems will get solved if they use family planning methods
Agree/disagree
6) What are the health needs of women , other than family planning and immunisation?
yes/no
7) Is women’s health only physical ?
a) What are the other aspects of women’s health?
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b)What kind of action would you take to address other than physical aspects ?
HEALTH SERVICE DELIVERY
1) How can we make a patient feel comfortable and satisfy him or her in absense of a doctor /
medicines in a health facility ?
COMMUNICATION
Read the following cases and answer the questions below:
(a) Ragini is a student of 9th class and has been remaining absent for long spells. One day her class
teacher summons her. Ragini enters her room. On seeing Ragini, class teacher starts bombarding
her with questions and gives her a lot of advise. Ragini retunrs home hopelessly. Infact she wanted
to empty her mind. She wanted to tell about her father who had been beating her up and her mother
after returning home all drunk. Ragini becomes more gloomy as the teacher had blamed her for
remaining absent! The problem faced by Ragini’s family aggravates and Ragini leaves the school for
ever.
Do you agree with the stand taken by the class teacher? Yes/No
Reasons
(b) Madhuri is waiting in the queue of the OPD of a general hospital. She is looking extremely nervous
and tensed. Standing in the line, she feels “what am I going to tell the doctor? would I be able to tell him
that I am not married and still I am carrying? No no... I will tell him that I am married. I dont want this
child. Make me free of this...” She clutches her mangalsutra nervously. When her turn comes, Madhuri
enters the room, trembling. The doctor asks her about her problem. For a few minutes Madhuri is not
able to say anything. Later gathering courage she says that she was married 10 months ago and that
she wants to abort. Dr gives one careful look at her and asks, “ you look below 18 and where’s your
husband? Go and bring him or bring some one and come tomorrow”. Listening to this, Madhuri rushes
out, all broken. Two days later, Madhuri tries to commit suicide by taking poison and she is admitted to
the emergency ward of the same hospital.
How the doctor should have handled the case of Madhuri?
(c) Sunita has gone to the Health Post with her sick baby who is having loose motions since 2 days. The
PHN checks her and starts explaining her the causes and prevention, “ You see, your child is de
hydrated. Now we have to re hydrate him
I am giving you this solution. It is called O R S
Sunita is confused and leaves the HP with the
baby.
Q1: Why do you think Sunita is confused. ?
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From all the above three cases please state what are the essentials of good communication. List any
five.
HEALTH EDUCATION
1) There is no use giving information to the women in the community because they do not understand
Agree/disagree
2) Instead of listening to women telling her what is best for her health is one of the best and less time
consuming way of health education .
Agree/disagree
3)ls it important to involve women in a discussion , in a health education session ?
Yes / No
Why?
4) List down three methods you use for health education, state whether mentioned methods can be
made interactive and more effective ?
Method
Whether can be made interactive
Yes/No
If yes , How?lf No Why?
WORK CULTURE AND PARTICIPATION
1) Following are the communication pattern during a meeting or a training session .
Diagram B :
Diagram A :
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1 )What pattern of communication do you see in the picture?
A. :
B.:
2)ln what ways do these patterns help or hinder the group process?
A.:
B.:
3)Which of the above do you prefer in a meeting that you conduct ?
4)How do you ensure this pattern ?
LEADERSHIP
Think of (OR name) one higher officer or immediate supervisor whom you like and dislike for his/ her
leadership or supervisory qualities? State five qualities that you like or dislike .
Qualities liked
Qualities disliked
(Some of the questions on perspective development are included in the interview guide that
follows)
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T-7.4B
Perspective development- interview guide
To be apllied to,
-6 CHVs (3 from each ward)
-6 ANMs (3 from each ward )
-4 MPWs (2 from each ward)
-2 FTMOs (1 from each ward)
-2 Disp. MOs (1 from each ward)
1) State one pleasant and one unpleasant episode in your work place when you felt most motivated
and interested in work and one when you hated your work place and you felt dismotivated and
frustrated ?
What factors contributed to the situation and to the way you felt ?
Inspiring Incident
Motivating factors
Frustrating experience
Demotivating factors
2)What can you as a person / collegue / sub-ordinate or supervisor make the workplace a pleasant
place to work in.
Person
Collegue
Sub- ordinate
Supervisor
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T- 7.5
Questionnaire for Trainees Midterm Evaluation
Objective:
To know change in perspective and their views about participatory training methods and contents and
trainers approach to involve them in the training process
Questionnaire to be applied to :
16 CHVs (8 from each ward)
4 ANMs and 4 MPWs (from H/E ward )
6 key trainers (3 from each ward )
6 FTMOs(3 from each ward)
6 Disp. M.O.s(3 from each ward)
1.
The following topics /subject were covered in the WCHP training. Categories them according to their
usefulness in your work from most useful to the least useful one.
Put (✓ ) in the appropriate box.
Most Useful
Topics covered in WCHP training
Useful
a) Gender and Health
b) WCHP activities, goal, objectives
c) Counselling
d) Communication
e) Infertility
f) RTIs/STDs
g) Sensitivity to feelings of a sick person
h) Effect of attitudes and human behaviour on the
work performance
i) Effect of socio-cultural-economic factors on
women’s health
2) From the topics you have found usuful, describe one situation from your routine
work, where the training has helped :
3) Has the training harmed your work ?
yes/no
If yes, how ? Describe the situation.
4) The following methods were used for training in above topics. Categories them
in terms of the method you enjoyed the most and the least.
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Training Method
Most enjoyed
Okay
Least enjoyed
a) Reading of a handout
b) Small group discussion and presentation
c) Lecture
d) Case-study and answering question
e) Group discussion and Brain storming
f) Sharing of personal experiences
g) Role plays
h) Slide show
5)What do you think of the following ?
Jked
Disliked
Why
a)
Circular sitting arrangement
b)
Inclusion of songs and games and
6) Which of the following categories are acceptable to you as trainers ? Make tick marks on the
appropriate answers.
a. PHN
b. ANM
c. MPW
d. CDO
e. FTMO
f. MO (DISP)
g. Honarary Clinicians
INTERVIEW SCHEDULE FOR TRAINEES
Interview Guide: To be apllied to,
-10 CHVs (5 from each ward)
-10 ANMs (6 from each ward )
-8 MPWs (4 from each ward)
-4 FTMOs (2 from each ward)
- 4 Disp. MOs ( 2 from each ward)
1) What did you feel about the WCHP training that you attended ? Why ?
2) State 3 things that you liked and disliked about the training
Liked
Why
Disliked
a)
c)
3)Was this training different from the trainings you have attended before ? In what way ?
4) (Only for CHV ):Do you think this training is useful in your work ? In what way ? Give one example
5) What did you think about the trainers who conducted this training ?
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T-7.6
Tool used to document providers’ perspective on quality of care and related aspects
1. We have been talking about ‘quality’, ‘quality of health care’, ‘quality assurance
measures’, etc.
What are the criteria of good quality of health care? In other words, what all make good quality of care?
List in order of importance and rank them. According to you, which criteria are present and the reasons
for absence of some of the criteria in the BMC health services?
Write your responses in the table given below.
Rank Criterion for good quality health
care, in order of importance
Present in the
If absent in the BMC
BMC health services
Reasons for absence
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
2. What do you think about the QA workshop/s, (their utility/usefulness)?
2.1
If you found them useful, why?
3. Have your ideas about quality of care changed after participation in the QA workshops
and/or interaction with the WCHP ?
Yes/No
Please specify.
4.
What steps have you taken to implement improvement of quality measures in yourfacility?
4.1
What problems have you faced while implementing these measures for quality of care ?
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T-7.7
Tool used to assess impact of capacity building related to QA on providers’ perspective
related to QA
(QA capacity building) R3
The work on QA mechanisms is a part of the action research introduced by the WCHP, e.g. for
improving effectiveness of the Referral System, finding out reasons for shortage of drugs through Drugs
Monitoring and understanding the providers’ Communication style through observation.
1.
During the course of carrying out these activities (towards improvement in quality of care) what
new things, if any, have you learnt?
1.1
How have your ideas changed?
(a) regaring women’s health
(b) quality of health care
1.2
Have your ideas regarding ‘systematic problem solving’ changed? Yes/No
If yes, how?
1.3
Have you learnt anything regarding collection and analysis of data?
1.4
Do you think that you could use these learnings in your routine responsibilities?
If yes, how? On what kinds of problems?
2.
How is your work supervised? On what basis?
Who supervises you?
On what basis?
l
How?
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3.
How do you supervise the work of your subordinates? On what basis?
Who supervises you?
4.
On what basis?
How?
Is the existing supervisory system supportive and problem solving one?
Yes
/No.
4.1
If yes, please specify.
4.2
If no, suggest in your opinion what could be done to put a supportive supervisory system in place?
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T-7.8
Midterm evaluation: Providers’ perspective on referral system
(Referral) R1
Respondent:
MOH
/ FTMO/ MOi/c
MO PRC
/MS/ Sr.MO
/MO Maternity Home
/RMO
/PHN/ANM
/MPW
(Note: MS, Sr.MO, RMO, MO PRC, MO Maternity Home to answer questions marked with * only.)
In March 1998, redesigned referral slip (yellow coloured with four parts) was introduced in the two project
wards. Here, we would like to have your feedback regarding the referral slip and the process involved.
*1.
What is your opinion on the utility of the new (yellow) referral slip?
*2.
What is your opinion about the format of the referral slip?
Needs modifications |
Is appropriate
|
Never used
|
Any other (please specify)
*2.1
If the referral slip 'Needs modifications’, kindly give your suggestions for improving the
format of the referral slip.
Currently a referral list is being used for monitoring purpose. The list gives an idea about the number of
cases, conditions for which referred and where they have been
3.
Yes
3.1
3.1.1
referred to.
Have you faced any difficulties in using the referral list?
No
Never used
I
I
If yes, please specify the problems faced in using the referral list?
If you have faced difficulties, kindly give your suggestions for overcoming these.
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*4.
Please give brief account of problems/ difficulties faced by you , if any, regarding (a)
clients
(b) referral centres (c) referring centres
Difficulty
Possible reason
Suggestion to overcome
for the difficulty
the difficulty
Client
Referral Centre
(Sec.Hospital,
PPC, Mat
Home,
Dispensary)
Referring centre
(HP, Dispensary,
Mat. Home,
PPC)
Have you received feedback from the referral centres?
5.
No
Yes
5.1 If yes, how? (Please
the appropriate option/s)
a. Report from the referral centres
b. Counterfoil of the referral slips
c. During ward level monthly meeting.
d. Informal meetings with the referral centres
c. Others (specify)
6.
Do you receive feedback from the referred clients?
Yes
6.1
No
If yes, what is the mode of receiving the feedback?
a) Counterfoils of the referral slips
b) Patients reporting back (back referral)
c) Through follow up in the community
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6.1.1
If yes, what kind of feedback do you receive?
6.2
If no feedback is received from referred clients, in your opinion what are the reasons
for this?
7.
How is the referral record maintained?
7.1
Please mention the difficulties, if any, in maintaining the record for referrals.
Communication between the referring unit and the referral unit is one of the factors that contributes to
effective referral.
*8.
your opinion, has there been a conscious effort at establishing communication channels
between the referring and referral units?
*9.
At present, what is the mode of communication between the referring and referral units?
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■ Women Centred Health Project ] Report of the End Evaluation
*9.1
Have you faced problems / inconveniences on account of the existing system of
communication regarding referrals?
Yes
Any other (Please specify)
No
i'.-
9.1.1
If yes, please describe your experiences in brief.
*9.1.2
In your opinion what steps need to be taken to avoid such problems I situations in
future?
*10.
In you opinion is back referral (higher level facility such as secondary hospital, maternity
home; referring patients to the lower level facility i.e. dispensary, health post) feasible?
Yes
No
*10.1
If Yes, for which conditions?
*10.2
If No, why?
Remarks and suggestions:
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T- 7.9
Interview guidelines for administrators
•
What do you think has been the contribution of WCHP to Public Health Department?
1.
2.
3.
4.
5.
6.
Gender
Quality
Training
IEC
Men’s involvement with Reproductive Health
Patients Charter
• What has been your personal experience of associating vyith WCHP?
1. Time Consuming
2. Unnecessary pressure and harassment
3. New ways of motivation
•
What from WCHP needs to be continued in your opinion? How & why?
•
What lessons can Public Health Department learn from WCHP for the future collaborations,
partnerships? (What activities / processes, methods)
•
What is your advise / suggestions for future initiatives like these?
•
What are the areas in which Public Health Department needs to strengthen itself & how?
1. Programmatic,
2. Strategy wise
RCH TRAINERS & STEPPING STONES TRAINERS
•
What in your opinion is the relevance of the RCH trainers training / Stepping Stones trainers
training?
•
What was your experience in applying what you learnt in that training?
•
What are your suggestions for transmitting this training to others in BMC? How can this be
institutionalized?
•
As a trainer what kind of support do you want from the system?
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Annexure 8
OUTLINE FOR MIDTERM EVALUATION
Evolved during March 22 - 24,1999.
ti
WHY MID TERM EVALUATION ?
•u •
•
To prepare for end-line evaluation, set into place indicators, tools and information systems for end
evaluation.
To review progress and suggest mid-term corrections.
To provide direction for post project in terms of feasibility and sustainability.
FOR WHOM?
•
For project team
•
For staff of two project wards and members of committees and sub committees.
•
For BMC policy makers.
©
For donors.
EVALUATE WHAT?
•
Achievements of / progress towards objectives. (See annexure 1 for Objectives and Indicators)
•
Activities undertaken / not undertaken with respect to time frame.
•
Identify problems and constraints within the project, those beyond the purview of the project.
•
Obtain feedback from project staff, staff of the two project wards, members of various committees
on achievements of project, weaknesses and suggestions for rest of the project period.
HOW? and WHO?
•
Indaicators have been developed for each of the objectives. The team will take the responsibility for
collecting and compiling the necessary data. Team members aasigned for a particualr objective or
indicator would compile all the availble data and develop tools for collecting relevant data. Tools
would be finalised after considering the comments and suggestions from other team members and
Ravi and Sunil. All team members would report the progress in the weekly staff meetings.
Ravi and Sunil have offered to take responsibility for interviewing the project staff and the higher
level BMC officials. They will be asked to develop interview schedules for these groups.
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INDICATORS FOR MID-TERM EVALUATION
w
00
Objectives_____________________________ Indicators /Variables
1. To implement selective reproductive health
at community health post, dispensary and
RPC level
Specific Objectives
1. To increase the range of services on prioritised
reproductive health problems
2. Involvement of men
3. Information, education and counseling
Output
1. A reproductive health package for primary level 1. Increased awareness in the community about
health care facilities
availability of services
2. Information, education and counseling centres 2. Number of persons availing of the services at
at PPCs/ maternity homes
each level
3. Development of skills (clinical, technical) and 3. Improvement in skills of staff
managing reproductive health clinics at health post 4. Increased use of manual and guidelines
and dispensarieslmplications of having clinics — 5. Number of facilities providing RH care services
— Trained staff— Place— Material
6. Number of men actively participating in
4. Manual and guidelines
treatment seeking
5. Men’s involvement in RH
7. Number of men aware of their partners’ problems
8. Number of men’s groups formed
Means of verification (sources of data)
O
5
CD
3
n
CD
-5
Q-
O
P
1. Studies to assess awareness in the
community
2. Records and formats for assessing
utilisation
3. Pre and Post observation for
assessment of skills — Technical
supervision checklist
4. Manual and guidelines
5. Special studies
cr
Manjiri, Anagha
o
o’
o
Sneha, Swati
o
Nandini, Alka
o
CD
Inputs
1. Training of staff (CHVs, ANMs, MPWs, PHNs,
FTMOs)
2. Setting up systems at health posts and
dispensaries (systems include supportive
supervision, technical supervision, CME, monthly
meetings, meetings with hospital staff)
3. Producing material and guidelines
1. Number of staff trained in reproductive health
care skills
2. Number of health posts, dispensaries where the
system is set up
3. Resources made available (time for producing
the materials)
4. Number of facilities using checklists
Sneha
Cl
rn
1. Training reports
2. Ward level reports, minutes of monthly
meetings at ward level
3. Observation
o
Objectives
4. Identifying staff and space with PRC
GO
K>
<0
2. To establish and implement quality
assurance
mechanisms
including
communication, treatment and referral
procedures
Specific Objectives:
Communication
1. to identify community needs for counseling
2. to identify community needs for treatment
3. to identify community needs for referral
4. to establish monitoring mechanism for these
5. to establish women friendly treatment procedures
Output
1. Identification of counseling, treatment and
referral needs
2. Better communication skills to all levels of
providers (CHVs, ANMs, MPWs, FTMOs)
3. Establishment of mechanisms to monitor the
communication skills
4. Establishment of counseling centres
5. Development of set of standards and a
Communication Manual.
Inputs
1. Baseline studies to identify needs
Indicators /Variables
Means of verification (sources of dat i)
5. Increased user satisfaction
4. Number of meetings — reports and
6. Increased provider satisfaction
minutes
7. Use of manuals, flow charts, guidelines by 5. Manuals and guidelines
number of facilities
6. Special studies —(Observation)
8. Use of manuals, flow charts, guidelines by
number of personnel
o
g
»—»
n
CD
3
CD
CD
P
Er1
no
CD
O
Swati
CD
1. To increase the proportion of users expressing
satisfaction regarding communication
2. Number of centres where communication
package is established
3. Number of personnel trained
1. Exit interviews
4. Number of beneficiaries or users availing such 2. Observations
centres
3. Ward level information regarding numbers
5. Tools developed, processes initiated
of counseling centres established and
6. Use of manual
their functioning
4. Manual
1. Exhibition of standards in the facility
5. Training reports
2. Number of facilities where these standards are 6. Special studies (user satisfaction)
displayed
o
o
zr
o
m
zs
CL
m
<
f
c
z:
Objectives
Indicators /Variables
3. Number of trainings for each cadre
2. Training to all levels of staff
3. Tool /checklist to monitor communication 4. Number of participants for each cadre
5. Process /system
(Communication study)
6. Number of facilities with monitoring system in
place
7. Increased user satisfaction
GO
GO
o
Referral
Objective
To improve existing referral system
Specific objectives
1. T o improve proportion of genuine referrals
2. To increase successful referrals
3. To initiate a system of back referrals
Output
1. Increase in number of referrals
2. Increase in rate of successful referrals
I
3. A system of back referrals set up
4. Involvement of all treatment centres
5. Manual
Inputs
1. Review of existing referral systems
2. Modification of tool (case paper)
3. Development and implementation of
monitoring formats
4. Training and orientation of primary and
referral level staff_____________________
Treatment
Objective
Means of verification (sources of data
1. Observation of use ofcharts, standards
exhibited
2. Reports of respective trainings
3. Interviews with trainees
4. Observation (on job) all cadres
5. Reports of baseline studies
6. Activity reports
7. Minutes of staff meetings
8. Minutes of other meetings
9. Special study (Exit interviews)
o
CD
n
CD
CD
Q-
Apte
X
CD
y
3
cd’
o
1. Comparison with baseline to assess increase
in extent of referrals
2. Proportion of successful referrals
3. Use of manuals
4. Number of facilities involved
5. Increased number of referrals from secondary
to primary level
1. Number of primary facilities involved
2. Number of peripheral, tertiary facilities involved
in the process
3. Number of staff trained in primary and
peripheral level facilities
4. Monitoring tools
1. Monthly reports from primary level
facilities
2. Minutes of meetings
3. Ward level data
4. Special studies
O
o
(D
1. Activities reports
2. Discussion with staff
3. Special study — Report of remarks of
personnel involved
4. Minutes of various meetings
m
in
<
c
o
Sneha, Swati
co
co
Objectives
To improve quality of care - clinical services
Output
1. Increased utilisation of primary level
facilities for RTIs, STDs, Menstrual problems,
ANC
2. Increase in technical knowledge and skills
of all levels of staff
3. Ongoing refresher training for all levels of
staff
4. Manual’and Protocol
Input
1. Baseline
2. Training for all levels of staff
3. Tools - checklists
4. Continued Medical Education for all levels
of staff
3. taken as point 7,8 under objective 6
4. To implement women friendly and
client friendly IEC
Specific Objectives
1. To establish links between BMC /IEC and
WCHP
Output
1. Institutionalisation of IEC philosophy and
strategies by WCHP
2. IEC Core Committee with members of IEC
Cell and WCHP
3. Involvement of ward level personnel in IEC
activities
Indicators/Variables
1. Increase in number of users for specified
conditions
2. Range of conditions treated at primary level
facilities
3. Number of cases seen, of specified
conditions — sexwise breakup
4. Number of staff trained
5. Number of staff using manual/protocol
6. Number of CMEs
7. Topics covered in the CMEs
8. Nature of participation in the CMEs
1. Proportion of providers using the tool
2. Number of CMEs and number of participants
3. Nature of participation
4. Availability of benchmark data
Means of verification (sources of data)
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2. Reports of technical supervision
3. Minutes of CMEs
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2. Minutes and reports of CME along with a
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3. Reports
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1. No. of IEC Cell staff internalising and
reflecting philosophy and method of
working propagated by WCHP
2. Regular meetings with high participation
3. Number of IEC activities initiated at ward,
dispensary and health post level
•
•
•
•
Interviews with I EC staff (To be prepared)
Minutes of meetings (available)
Observation of meetings (To be prepared)
Samples of material prepared at ward level
(To collect after survey)Baseline and endline
FGD / Surveys (To be prepared)
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Objectives
Means of verification (sources of data)
Indicators/Variables
•
•
1. Number of training programmes
2. Number of exposures/outside workshops •
•
attended by IEC Core Committee members
3. Number of activities in which members of the •
IEC committee were involved
•
Number
and content of WCHP contacts with
Ongoing dialogue and personal contact of WCHP
IEC Cell
members with IEC Cell members
Input
1. Training and workshops with IEC Core
Committee
2. Involvement of IEC Core Committee in various
activities of WCHP
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Specific objective
2. Development of materials with participation of 1. More people understanding messages
clients (posters, flip charts, street plays, songs, 2. Number of IEC cell and ward staff demonstrating
increased understanding
etc.
3.
Number
of contacts with community(process
Output
indicators to be developed)
1. Material prepared in the prescribed way
4.
Number
of materials produced with participation
2. IEC staff and ward staff understanding
of users
principles and process of preparation of good
health education material
Input
1. Number of persons trained
1 .Training of ward staff
2. Number of training programmes
3. Contents of training programmes
4. Number of persons trained
2. Workshop with IEC cell staff
5. Number of training programmes
6. Topics and issues covered in the workshops
7. Nature of participation
8. Number of meetings
3. Meetings at community level
9. Number of participants
10. Issues discussed
Reports (available)
Report (To prepare format)
Report (To prepare format
To prepare reports
Interviews of WCHP members
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Baseline and Endline survey
Interviews (community)
Pre and Post training scores
Observations — supervisory checklist
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analysis
Reports
Pre and Post training scores
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Objectives
Indicators/Variables
Means of verification (sources of data)
Dr. Soni, Apte
(systems)
Sneha
(attitudes)
5. To establish mechanisms for evaluating
quality of care
Specific Objective
1. To establish supportive supervision system
2. To establish system for process evaluation
of training
3. To establish system for process evaluation
of Quality Assurance
4. To establish system for process evaluation
of ability to meet women’s information and
support needs.
Output
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1. System for Supportive supervision
2. Quality Assurance monitoring system
3. System for ongoing assessment of women’s
needs including counseling and information
needs
5. Manual for Quality Assurance including a
section on process evaluation
Inputs
1. Baseline studies
2. Tools for evaluation of QA aspects
(checklists)
3. Quality Assurance package
4. Quality Assurance committees
5. Training of providers
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1. Monthly reports of the MOsH
1. Number of supervisors using the checklist
3. Reports by the facilities regarding use of the
2. Number of facilities having / using Quality
QA system
Assurance system
3. Number of support groups formed in the community
4. Activities undertaken by these support groups
5. Number offacilities using Quality Assurance manual
6. Number of personnel using the QA manual
1. Interviews with the QA committee members,
1. Number of facilities having Quality Assurance
other staff
committees
at the facility and users of the services
2. Participation of members in the working of the 2. Minutes of monthly meetings at ward level,
committees
documenting the problems faced at the
3. Activities and recommendations by the
individual facility level and actions taken
committees
3. Minutes of the monthly meetings of the QA
4. Change in attitude of the providers towards
committees
Quality Assurance
5. Number of persons trained—facility and cadre
wise distribution
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Specific objectives (contd.)
To assess effectiveness of interventions on
6. perceptions of quality of services of users
7. indicators of Quality of Care
8. indicators on efficiency and effectiveness of services
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Specific objectives (contd.)___________________
9. To examine cost efficiency of all primary health care
activities with special emphasis on reproductive health
care package.
Output
1. Cost effective Reproductive Health package at
primary level facilities
Inputs
,1. Costing study for assessing the existing cost of
services provided at the primary facilities
2. Efforts towards Reorganisation of health care facilities
3. Training of staff concerned
4. Re-allocation of resources such as space, staff,
equipment, drugs
5. Introducing monitoring mechanisms
I n d i cators/Variables
1. Increased utilisation of primary facilities for
reproductive health problems
2. Change in attitude and practices of providers
and users
3. Increase in proportion of clients expressing
satisfaction
4. Change in opinion about the BMC (+ve opinion)
5. Creating awareness and demand for quality of care
Means of verification (sources of datp)_______
1. Baseline and Endline reports,
utilisation data
2. Special studies
3. Pre- post (attitudes)
4. Provider study (perceptions)
5. Reports, Focus group discussions,
exit interviews (community —
awareness, demand, perception)
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Apte
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1. Increased utilisation of health posts/ reorganised
units for women’s problems
2. Number of facilities integrated or reorganised
1. Monthly reports from the health
posts, dispensaries and integrated
health centres
2. Ward level data using the checklists
prepared by the WCHP
1. Increased utilisation for women’s conditions
2. Number of meetings with re-organisation as an 1. Assessment studies
2. Special studies — providers and
agenda
3. Recommendations of the re-organisation sub users
3. Supervisory checklist of the MOH
committee acted upon
4. Number of activities undertaken in the direction 4. Minutes of the meetings
of re-organisation — reports, issue taken up in the
CME etc.
5. Number of times/ instances when health post
and dispensary shared resources____________
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Objectives
Indicators/Variables
Means of verification (sources of di ta)
6. Perceptions and attitudes towards re-organisation
7. Number of staff made aware of the reorganisation
(concept)
8. monitoring system in place
6. Capacity building of staff in these two wards
and others in the BMC (Project staff, MIS cell,
Policy makers etc.)
1. Perspective development
2. Action research
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3. Monitoring and evaluation
4. Treatment
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1. Qualitative analysis of greater sensitivity to e.g.
gender, participatory modes, supportive supervision
etc.
2. Improved communication
3. Number of persons included in various perspective
development sessions
1. Number of action research studies involving BMC staff
2. Increased ownership of funding and greater
commitment for follow up
3. Number of concrete actions resulting from these
research studies
1. Number of staff involved in designing monitoring
and evaluation system
2. Number of staff trained in monitoring and evaluation
3. Number of tools prepared/refined/improved
4. Feed back of staff on utility of tools and monitoring
and evaluation system
1. Number of clinical trainings done for clinicians,
ANMs / MPWs, PHNs, CHVs
2. Number of these categories of personnel trained
3. Number of laboratory technicians trained
4. Improved knowledge and practices
5. Mechanisms for follow up of clinical trainings : no.
ofCMEs
Pre and post scores
Self evaluation exercise
Communication study scores
Reports
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List of studies
Reports of studies
Interviews with ward staff,
project staff
Case studies
Process reports
Training reports
New tools
Process reports
Interviews
Training reports, manuals
produced
Pre-Post scores
Monthly reports
Content analysis of CME
Observation of skills—through
technical and supportive
supervision checklists. .
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6. Percentage of staff observed who use protocols correctly
1. Number of key trainers trained
5. Trainings
2. Manuals for key trainers
3. Number of key trainers with increased training
skills and knowledge
6. Acceptance of WCHP trainings modules in BMC 1. Use of modules by BMC Training Cell
2. Methods of training needs assessment followed
by training cell of the BMC
7. To establish communication and referral channels 1. Clear and established systems both-ways
between community, health posts, PRC, referral unit (includes back referral)
2. Increased awareness among community about
with respect to services
services available at each level
3. Increased satisfaction of staff
4. Number of successful referrals
5. Number of times referral agenda taken up at
monthly ward meeting
8. To establish communication channels for better 1. Number of forums established at each level for
voicing and collectively addressing the problems
management of the facilities
2. Number of problems addressed collectively and
feedback given to the facility
9. Collective CME sessions with doctors for Health 1. Number of doctors of various facilities satisfied with
CMEs also as a communication channel
Post, Dispensaries and Hospitals
2. Number of CMEs, ranges of topics, attendance
and participation
7. To disseminate and mainstream the
learnings of the project
Specific Objectives
1. To establish sub-committees and committees
2. To establish linkages with other programmes and
cells within BMC
3. Upscaling of selected interventions___________
Means of verification (sources of data
Indicators/Variables
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Special study — Observation
Pre-post
Interviews of the key trainers (to
be prepared)
Observations (to be prepared)
Training reports
Training Cell, list of training
material
Minutes of the monthly meetings
of the MOsH
Referral slips
Health Post records
Special Studies (interviews with
community)
Interviews with staff
Monthly report
Minutes of meetings
Minutes of meetings held by
forums, facility level meetings, monthly
meetings of the MOsH, CMEs
Interviews with doctors
CME Reports
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Objectives
Indicators/Variables
Means of verification (sources of data)
Output
1. Formation of committees
2. Linkages with other cells and programmes within
and outside the BMC — established and functional
3. Research cell established in the BMC
4. MIS and training cell in the BMC strengthened
Inputs
1. Meetings
2. Staff time
3. Guidelines
1. Number of meetings by committees
2. Number of participants
3. Number and nature of recommen
dations made by the committees
4. Process indicators for various cells
5. Perceptions of committee members
about usefulness of the committees
6. Number of non governmental
organisations (NGOs) participating in
BMC activities — number and nature of
activities
7. Participation of the BMC in NGO
activities — number and nature of the
activities
8. Number of formats, checklists, tools,
manuals produced by the project, being
used outside the project area in other
BMC wards
9. Number of specific projects upscaled
10. number of interventions upscaled
1. Reports and minutes
2. Interviews with members of the
committees, policy makers
3. Special studies (perceptions)
4. Health post records
5. Interviews with those involved
6. Manuals
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| Women Centred Health Project I Report of the End Evaluation
ANNEXURE 1
OBJECTIVES
1.
To implement selective reproductive health at community health post, dispensary and RPC
levels.
•
Increase range of services on prioritised reproductive health problems
•
Involvement of men
•
Information, education and counseling
2.
To establish and implement quality assurance mechanisms including communication,
treatment and referral procedures
•
Procedures for identification of counseling, treatment and referral needs
•
Monitoring mechanisms in place for communication, treatment and referral needs
•
Women friendly treatment procedures
•
Clinical protocols
3.
To establish communication and referral channels between community, health posts,
dispensaries PPCs (women health centres), and peripheral hospitals and tertiary hospitals.
4.
To implement women friendly and client friendly IEC
•
Links between IEC cell of the BMC and the project
•
Development if materials with participation of clients
•
Training of staff in using these
5. To establish monitoring and evaluation systems.
•
supportive supervision system
•
systems for process evaluation for
- training
-QA
- ability to meet women’s information and support needs.
•
measured effects of intervention on
- attitudes and practices of health care providers.
- perceptions of quality of services of users
- indicators ofQOC
- indicators on efficiency and effectiveness of services.
•
Cost efficiency of all primary care services with special emphasis on selected
reproductive health services.
6. Through all activities build capacity of staff in two wards and BMC
- perspective development
- action research
- monitoring and evaluation
- IEC skills and process of preparation of materials.
- treatment and referral for selected reproductive health
- training modules integrated into ANMs, MPWs, FTMOs.
- establish a research cell in the BMC
7. To disseminate and mainstream learnings from the project
- structures within the project, committees and subcommittees.
- relationship with other programmes AIDS unit, CSSM
- feasibility and sustainability, upscaling of selected interventions.
338
1
| Women Centred Health Project I Report of the End Evaluation
WCHP Team (2003)
r»-;-
I
Dr. Usha Ubale
Renu Khanna
Swati Pongurlekar
Korrie de Konning
Ashalata Rilkar
Sneha Khandekar
Bharati Ghule
Anagha Pradhan
Veena Savinkar
Pravina Kukade
Shailaja Ajgarni
Vidya Lad
Shubhangi Joshi
Rashmi Shinde
Dhananjay Gaikwad
Sweta Barve
Jayant Pawar
Deputed by Public Health Department of Municipal Corporation of Greater Mumbai
Name of the person
Duration
Dr. Usha Ubale, AHO (Schools), Project Coordinator WCHP
1996-2003
Swati Pongurlekar, CDO, Training Coordinator WCHP
1996-2003
Girish Apte, Statistician, Data Manager WCHP
1996-1999
Vijaya Mogre, PHN, IEC Officer
Ashalata Rilkar, ANM, Librarian, traslator, Counsellor
1996-2003
Bharati Ghule, FFW, IEC Assistant, Counsellor
1996-2003
Veena Savinkar, FFW, Training Organiser
1996-2003
Shubhangi Joshi, Typist
1996-2003
Shalaja Ajgarni, CHV
1996-2003
Earlier Members of WCHP Team
Dr. M. I. Soni
Dr. Nandini Roy
Dr. Padmavathi Dayavarishetty
Manjiri Maslekar
Dr. Aastha Pandey
Gurudas Pilankar
Dr. Uddhav Burute
Seema Raut
Archana Bondre
Rohini Pawar
Meera Limaye
Chinmaya Badale
Asha Cherian
Suman Miranda
Research Coordinator
Research Officer
Research Officer
IEC Officer
Research Officer
Research Officer
Research Officer
Research Assistant
Research Assistant
Research Assistant
Project Officer
IEC Officer
Administrative Officer
Administrative Officer
339
Women Centred Health Project
Report of the End Evaluation
Women Centred Health Project
Dy. Executive Health Officer
(FW&MCH) First Floor,
F/S Ward Office,Brihanmumbai
Municipal Corporation,
Parel, Mumbai 400 014
Tel: 91-22-26162436/26186607
e-mail: wchpadmn@vsnl.net
Royal Tropical Institute
Mauritskade 63
P.O.Box 95001
1090 HA Amsterdam
The Netherlands
Telephone No. 0031 -020-5688 239
SAHAJ
1, Tejas Apartments,
53Haribhakti Colony
Old Padra Road,
Vadodara - 390 007, INDIA
Telephone No: 91-265-2340223
340
WCHP Team (2003)
Dr. Usha Ubale
Renu Khanna
Swati Pongurlekar
Korrie de Koning
Ashalata Rilkar
Sneha Khandekar
Bharati Ghule
Anagha Pradhan
Veena Savinkar
Pravina Kukade
Shailaja Ajgarni
Vidya Lad
Shubhangi Joshi
Rashmi Shinde
Dhananjay Gaikwad
Sweta Barve
Jayant Pawar
Deputed by Public Health Department of Municipal Corporation of Greater Mumbai
Name of the person
Duration
Dr. Usha Ubale, AHO (Schools), Project Coordinator WCHP
1996-2003
Swati Pongurlekar, CDO, Training Coordinator WCHP
1996-2003
Girish Apte, Statistician, Data Manager WCHP
1996-1999
Vijaya Mogre, PHN, IEC Officer
1998-2002
Ashalata Rilkar, ANM, Librarian, traslator, Counsellor
1996-2003
Bharati Ghule. FFW, IEC Assistant, Counsellor
1996-2003
1996-2003
1996-2003
1996-2003
Veena Savinkar, FFW, Training Organisor
Shubhangi Joshi, Typist
Shalaja Ajgarni, CHV
Earlier Members of WCHP Team
D- M. I. Som
Dr. Nandim Roy
Dr. Padmavathi Dayavarishetty
Manjin Maslekar
Gurudas Pilankar
Dr. Uddhav Burute
Seema Raul
Archana Bondre
Rohmi Pawa’
Meera Limaye
Chinmaya Badale
Asha Cherian
Suman Miranda
Research Coordinator
Research Officer
Research Officer
IEC Officer
Research Officer
Research Officer
Research Assistant
Research Assistant
Research Assistant
Project Officer.
IEC Officer
Administrative Officer
Administrative Officer
Women Centred Health Project
Dy. Executive Health Officer
(FW&MCH) First Floor.
F/S Ward Office,Brihanmumbai
Municipal Corporation,
Pare!, Mumbai 400 014
Tel: 91-22-26162436 / 26186607
I
SAHAJ
1. Tejas Apartments.
53 Haribhakti Colony
Old Padra Road,
Vadodara - 390 007, INDIA
Telephone No: 91-265-2340223
e-mail :sahaj2006@dataone.in
1
Royal Tropical Institute
Mauritskade 63
P.O.Box 95001
1090 HA Amsterdam
The Netherlands
Telephone No. 0031-020-5688 239
Position: 4700 (1 views)